First inspection of newly registered domiciliary care agency rated Good overall and across all five key questions. Recommendations made for improvements in medicines administration recording and recruitment risk assessment documentation, with minor concerns over supervision frequency, staffing continuity and IPC policy.
Concerns (7)
moderate
Medication management
: “Two people's MARs records were not always completed to demonstrate the person had received their medicines as required.”
moderateRecord keeping: “The registered manager confirmed they undertook a risk assessment should they employ the member of staff prior to all satisfactory checks being completed. No records of this assessment were being completed.”
minorSupervision / appraisal: “Records confirmed staff received supervision however this supervision was not in line with the providers policy which confirmed staff should receive supervision, 'At least every 8 weeks'.”
minorCare planning: “one person's care plan had minimal information relating to the person's personal information. Such as how they wished to be addressed, their eye colour and religious preferences.”
minorStaffing levels: “some people and one relative experienced change's to regular staff which they found unsettling... 'Normally okay but not enough during the summer times'.”
minorInfection control: “The provider's infection prevention and control policy was not in line with current guidance in relation to protective eye wear.”
minorPerson-centred care: “one person wished to have a female member of staff support them with their personal care rather than a male. They told us this was not always possible. These wishes had not recorded within their care plan.”
Strengths
· Staff received training in safe administration of medicines with annual competency checks
· People felt safe and well-treated by kind, helpful staff
· Staff had access to bespoke training (diabetes, death and dying, supporting depression) in addition to mandatory training
· Care plans regularly reviewed at 4 weeks, 8 weeks then yearly or as needs change
· Quality assurance systems in place covering health and safety, care plans, incidents, complaints and management meetings
Quality-Statement breakdown (24)
safe: Using medicines safelyNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Staff working with other agencies; supporting people to access healthcare servicesNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot 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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving care; Working in partnership with othersNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated