All Seasons Care Limited, a small domiciliary care agency in Birmingham serving 22 people, retained an overall Good rating following a focused inspection of Safe and Well-Led domains. While care delivery and safety practices were broadly strong, governance weaknesses around care plan detail, body map guidance for prescribed creams, and unsystematic medicines audit recording led to a Requires Improvement rating for Well-Led.
Concerns (4)
moderate
Medication management
: “body maps were not always used to show staff exactly where to apply creams”
moderateCare planning: “Systems to monitor the quality of people's care had not enabled the registered manager to identify the need for more detail in some people's care plans.”
moderateGovernance: “Medicines management systems had not assisted the registered manager to identify guidance for staff on the use of prescribed creams was limited.”
minorMedication management: “the recording of checks was not systematic. The registered manager stated they planned to include a record of these checks in their quality assurance monitoring.”
Strengths
· People felt safely supported and were happy with their care; staff knew people's needs well.
· Adequate staffing levels with safe recruitment practices including DBS checks.
· Strong safeguarding awareness among staff; no recent safeguarding concerns at time of inspection.
· Effective infection prevention and control practices in place.
· Open learning culture encouraging staff to report mistakes and concerns.
Quality-Statement breakdown (11)
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive, and empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careGood
well-led: How the provider understands and acts on the duty of candourGood