LJ Sure Mercies is a domiciliary service supporting people in their own homes in the community. At the time of our assessment the service was supporting 8 people. Assessment activity took place between 16 April, and we visited the service on 17 September. This was the first assessment of this service carried out under our single assessment framework. We looked at 14 quality statements: safe systems and pathways, safeguarding, involving people to manage risk, safe environments, infection prevention and control, safe and effective staffing, medicines optimisation, shared direction and culture, capable, compassionate and inclusive leaders, freedom to speak up, governance and assurance, partnership and communities and learning, improvement and innovation. During the assessment, we received feedback from relatives of people who used the service, staff, registered manager and office staff. We looked at a range of records, policies and procedures and how medicines were managed.
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LJ Sure Mercies, a small domiciliary care agency on its first inspection, was rated Requires Improvement overall, with weaknesses in medication management, risk assessment documentation, and quality assurance systems failing to identify its own shortfalls. Caring, effective and responsive practice were all rated Good, with staff described as kind and well-trained and the registered manager taking prompt remedial action during the inspection.
Concerns (8)
moderateMedication management: “The registered manager did not have clear protocols in place for staff to follow when PRN medicines were needed.”
moderateMedication management: “these audits did not identify that staff were not always using the correct codes for administering medicines.”
moderateCare planning: “People did not always have risks to their safety assessed and planned for... there was not enough information to mitigate the risk.”
moderateCare planning: “on two occasions where risk assessments for specific conditions were not completed accurately. This meant staff did not have the information to care for people in a safe way.”
moderateGovernance: “The registered manager did not always have effective quality assurance systems in place to monitor service delivery as they had not identified the issues we found.”
minorRecord keeping: “the registered manager was not documenting this correctly. They told us, this was a recording error, and they would update their practice going forward.”
minorSupervision / appraisal: “There were some gaps in staff's supervisions, however, the registered manager was addressing this when we inspected.”
minorRecord keeping: “Senior staff were completing spot-checks but they did not always record this work. The registered manager was aware of the need to record this information.”
Strengths
· Staff were recruited safely with appropriate DBS checks completed prior to starting work.
· Effective safeguarding systems in place; safeguarding discussed in staff meetings and staff understood how to report concerns.
· Infection prevention and control measures were effective with adequate PPE supply.
· Accidents and incidents were recorded and discussed in team meetings to improve practice.
· People's care was personalised and staff knew people well; care plans included background, likes, dislikes and hobbies.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and management; Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversity; Supporting people to express their viewsGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood