Azelea Care Solutions Ltd, a small domiciliary care agency in Luton, was rated Requires Improvement overall on its first inspection in May 2023, with Safe and Well-led both requiring improvement due to incomplete risk assessments and the absence of a registered manager. People and relatives spoke highly of caring, punctual staff and a person-centred culture, with Effective, Caring and Responsive all rated Good.
Concerns (3)
moderate
Care planning
: “Not all risks to people had been assessed. For example, people with risks related to heart conditions and stroke or who were prescribed high risk medicines such as blood thinners.”
moderateGovernance: “Provider oversight had not been effective as it had not identified until this process, the shortfalls in relation to risk management we found at this inspection.”
moderateLeadership: “The location has a condition of registration that it must have a registered manager, but it does not have one.”
Strengths
· People felt safe and received continuity of care from the same staff teams who knew them well.
· Staff had received safeguarding training and understood how to report concerns.
· Medicines were administered correctly and staff competency checks were completed by the manager.
· Staff supported people in line with the Mental Capacity Act and understood consent principles.
· People and relatives spoke highly of the caring, punctual and patient approach of staff.
Quality-Statement breakdown (25)
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: 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: 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: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood