Ray of Sunshine Care Ltd is rated Good overall at its first CQC inspection, with staff delivering kind, person-centred care underpinned by strong training, supervision and external partnerships. The Safe domain requires improvement due to inaccuracies in medicines administration records and insufficient risk guidance in some care plans, though no medication omissions were identified and management took prompt remedial action.
Concerns (3)
moderate
Medication management
: “The information recorded on people's electronic medicines records was not always fully accurate, up-to-date or complete... staff made inconsistent use of administration codes.”
moderateCare planning: “Some people's care plans lacked clear guidance for staff on how to keep them safe. This included insufficient guidance in supporting people with their mobility needs and the expected use of their care equipment.”
moderateGovernance: “The effectiveness of audits in relation to people's care plans and the management of their medicines needed some improvement, as these had not identified the concerns we found on inspection.”
Strengths
· People and relatives felt staff delivered safe, kind and caring support, with staff going beyond expectations such as visiting in personal time and providing Christmas meals.
· Robust pre-employment recruitment checks ensured staff suitability to work with vulnerable people.
· Staff received a comprehensive induction, wide-ranging training and regular one-to-one supervision from management.
· Effective collaboration with external agencies including GPs, district nursing and social care professionals to achieve good outcomes.
· Management promoted an open, person-centred culture; staff felt well-supported and able to raise concerns without fear.
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: 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: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective and timely careGood
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 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 concernsGood
responsive: End of life care and supportGood
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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staffGood