AW House is a Good-rated domiciliary care service on its first CQC inspection, with strong person-centred care, safe medicines management, and a well-regarded registered manager. The Well-Led domain was rated Requires Improvement due to failure to submit three safeguarding notifications to CQC and the local authority, incomplete best interest decision records, and insufficiently robust governance audits.
Concerns (5)
critical
Safeguarding
: “the registered manager had failed to notify both the CQC and local authority...had failed to notify the CQC or local safeguarding of 3 incidents.”
moderateGovernance: “the registered manager did not ensure the audits were robust and had failed to identify concerns we found during our inspection.”
moderateConsent / capacity: “Mental capacity assessments had been completed...but there were no records of how to support people in their best interest, or lasting power of attorney records.”
minorRecord keeping: “missing information in some care records, including signatures, prescribed creams not being recorded on an eMAR...minor inaccuracies and some missing information.”
minorIncident learning: “the quarterly report we reviewed did not provide a clear indication whether incidents related to the same person.”
Strengths
· People and relatives felt safe and expressed high satisfaction with the care and support provided.
· Medicines were managed safely, with staff trained and competency-checked regularly.
· Care plans were personalised and person-centred, reflecting individual preferences, communication needs, and cultural background.
· Staff received thorough inductions, regular supervision, competency checks, and appropriate training.
· Registered manager was visible, approachable, and fostered a positive, inclusive team culture.
Quality-Statement breakdown (25)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
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, timely careGood
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: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: How the provider understands and acts on the duty of candourRequires improvement
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 staffGood
well-led: Continuous learning and improving careGood