First inspection of a small newly registered domiciliary care agency supporting one person rated Requires Improvement overall, with concerns around safeguarding referrals, MCA understanding, training robustness, complaints handling and notification of CQC. Caring was rated Good, with positive feedback from a relative about person-centred, dignified care.
Concerns (8)
critical
Safeguarding
: “Safeguarding procedures had not always been followed... had not recognised the need for a safeguarding referral.”
criticalIncident learning: “The registered manager was not confident about when they needed to inform CQC of events that happened in the service as required by regulation.”
moderateGovernance: “The registered manager was not fully able to demonstrate a robust understanding of their regulatory requirements.”
moderateStaff training: “We were concerned the version of the Care Certificate being used meant staff were completing on-line training in over thirty different areas within a week.”
moderateConsent / capacity: “they were not able to demonstrate confidence in their understanding of MCA and deprivation of liberty and felt they would benefit from additional training”
moderateCare planning: “a risk assessment in relation to moving and handling lacked the detail needed to make sure staff knew what to do to ensure the person's safety.”
moderateComplaints handling: “Complaints were not always managed appropriately... had not demonstrated a robust approach in making sure procedure was followed”
moderateGovernance: “At the time of the inspection quality assurance systems were being developed.”
Strengths
· Caring and respectful approach praised by relative who described care as 'Beautiful' and 'Personalised and friendly'
· Staff maintained people's privacy and dignity, closing curtains and doors during personal care
· Person-centred care plans developed with the person and their relatives
· Safe recruitment processes were in place
· Effective use of PPE and up-to-date infection prevention and control policy
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated