Date of assessment: 1 April- 30 May 2025. Happy Family Care Services Limited is a care at home service for older people. The service provides support to 21 people. We undertook this assessment to follow up on concerns identified at the last assessment. At our last assessment in January 2023, this service was rated requires improvement overall. The key questions for safe, effective and well-led were rated required improvement and the key questions caring and responsive were rated good. At that assessment we found breaches of regulation relating to consent, safe care and treatment and staffing. At this assessment we found the provider had made improvements and they were no longer in breach of regulations. The provider had a proactive and positive culture of safety with clear systems in place for reporting, investigating and learning from incidents. Lessons were learnt to continually identify and embed good practice. Safe systems of care were established and there were clear safeguarding procedures in place that were followed when needed. Risks to people’s health and safety, which included their environments, were assessed and managed. The provider ensured there were enough suitable staff in place to support people. Staff were supported through an ongoing system of training and supervision. Infection control risks were properly managed and people’s medicines were managed safely. People’s needs were assessed before they started using the service and on an ongoing basis to ensure they were achieving the best outcomes. The provider worked with other professionals where needed in meeting people’s needs and this included meeting their health goals. Care was provided in accordance with legislation and current standards in line with their valid consent. The provider had a shared vision in the running and management of the service. The registered manager was capable and passionate about his purpose, which involved setting up a service to meet the unique needs of the Tamil community. He had originally provided a day centre service to older people in his local community and opened this service at the direct request of people he worked with. This included ensuring people’s cultural and language needs were met by staff who understood these. Staff were clear about their roles and responsibilities and told us they felt confident their feedback and concerns were listened to. The provider carried out an ongoing system of audits to ensure improvements were made where needed and professionals spoke positively about their working relationship with the provider.
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Happy Family Care Services Limited received an overall rating of Requires Improvement at its January 2023 inspection, with four regulatory breaches identified covering safe care and treatment, staffing, need for consent, and governance. Key failings included inadequate risk assessments, unsafe medicines management, insufficient staff training and supervision, non-compliance with MCA principles, and weak governance systems that had persisted unaddressed since the previous inspection in 2021.
Concerns (11)
criticalCare planning: “Some of the risk assessments we viewed did not include a management plan to mitigate the assessed risks. For example, where a person was assessed at a medium risk of falls there was no plan in place.”
criticalSafeguarding: “Some staff had limited knowledge of English language and the safeguarding and whistleblowing procedure. The provider's safeguarding policy was only in English.”
criticalMedication management: “2 people were prescribed paracetamol 'as required' medicine but guidance for staff was not available for when to administer this medicine.”
criticalStaff training: “[The training] is very basic. The essential training for staff does not cover mental side of it, it is left out. I don't know if all carers know how to deal with it.”
criticalConsent / capacity: “People were assessed based on the principles of the mental capacity assessment when they first started using the service. These assessments were not time or decision specific.”
criticalGovernance: “The provider did not have an effective governance systems in place to monitor the care delivery. This resulted the provider failing to pick up and/or act on a number of issues.”
moderateIncident learning: “Records could not be found for these. We also saw that incident and accident monitoring log had not been updated since September 2022.”
moderateSupervision / appraisal: “Records showed that some staff did not have a supervision for more than 6 months. Spot checks lacked details as to what specifically was looked at during the observation.”
moderateLeadership: “We could not determine what specific areas of the service the managers were accountable for, including who was responsible for carrying out supervisions and appraisals.”
moderateRecord keeping: “The registered manager told us that some checks were completed by the management team... but that there wasn't a record made which meant it was difficult to track any actions identified.”
minorCommunication with families: “Communication should be a lot better; it really is not clear who I should go to if there are changes in [my relative's] condition.”
Strengths
· Safe staff recruitment procedures in place including DBS checks and references before staff started working with people.
· Infection prevention and control policy was up to date and staff had necessary PPE supply following national guidance.
· Family members reported staff attended visits on time and stayed for the correct duration.
· Staff supported people with eating, drinking and healthcare needs sensitively and in line with individual preferences.
· Service specialised in South Asian ethnicity support, recruiting Tamil-speaking staff to communicate in people's native language.
Quality-Statement breakdown (13)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Staff support; induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law
Good
effective: Supporting people to eat and drink enough; Supporting people to live healthier lives; Staff working with other agenciesGood
well-led: Continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Planning and promoting person-centred, high-quality care; Engaging and involving people using the serviceGood
well-led: Working in partnership with others; Duty of CandourGood