Date of assessment 24 April 2024 to 7 May 2024. The assessment included a site visit to the service on 24 April 2024. Gloriavd Health Care Ltd is a domiciliary care agency. It provides personal care to people living in their own homes. We assessed the service because there had been concerns identified regarding the quality and safety of the service. We looked at 9 quality statements; Safeguarding, Involving people to manage risks, Safe and effective staffing, Medicines optimisation, Independence choice and control, Equity in experiences and outcomes, Freedom to speak up, Governance, management and sustainability and Learning, improvement and innovation. We found a breach of the legal regulation in relation to governance as quality assurance systems were not effective. We have asked the provider for an action plan in response to the concerns found at this assessment. The overall rating for the service is requires improvement.
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Gloriavd Health Care Ltd received an overall rating of Requires Improvement at its first inspection, with regulatory breaches identified in safe medicine administration and record-keeping/governance. Strengths were noted in caring and responsive domains, with staff praised for dignified, person-centred care and effective partnership working with external professionals.
Concerns (5)
criticalMedication management: “Medicine charts did not document which staff member had administered medicines. This was a breach of regulation 12 (Safe care and treatment).”
criticalRecord keeping: “The provider failed to record the process of assessing and mitigate risks for people who use the service. This was a breach of regulation 17 (Good governance).”
criticalCare planning: “The provider failed to record the process of assessing care needs for people who use the service. This was a breach of regulation 17 (Good governance).”
moderateGovernance: “Audits had not identified all the issues found on the inspection, for example the audits had not identified medicine charts did not document which staff member had administered medicines.”
minorSupervision / appraisal: “Staff told us they received monthly supervision and regular competence checks; however these were not dated.”
Strengths
· Staff received medicines training and competency checks, with monthly medicines audits completed and actions implemented.
· Staff levels were safe and staff were recruited safely, including DBS checks, employment history and references.
· Staff treated people with dignity and respect, involving them in care decisions and promoting independence.
· Care plans contained detailed personalised information including communication needs and end of life wishes.
· Positive staff culture with regular supervision, team meetings, and surveys for staff and people using the service.
Quality-Statement breakdown (20)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires 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: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
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 concerns; End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Working in partnership with others; duty of candourGood