Date of Assessment: 17 December 2024 to 13 January 2025. The service is a domiciliary care agency and provides personal care to people living in their own homes. Not everyone was receiving personal care. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. At the time of this inspection 49 people were receiving support with personal care. The assessment was prompted following a review of information we held about the service. We found 1 breach of regulation in relation to safe care and treatment. Plans were in place to support people to manage risks but they needed some development, so risks were managed effectively, and staff had the guidance needed to support people safely. However, managers investigated incidents. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Processes were in place for people who required support with their medicines. The provider had governance systems in place to monitor and improve the quality of the service, but these were not always effective. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We have asked the provider for an action plan in response to the concerns found at this assessment.
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Diverse Care Services is rated Good overall following a focused inspection of safe, caring and well-led domains, with well-led dropping to Requires Improvement due to ineffective care plan audits that failed to identify gaps in risk assessment guidance. People and relatives were overwhelmingly positive about staff conduct and the management team, but the provider must strengthen governance processes to ensure audits reliably identify and address areas for improvement.
Concerns (3)
moderateCare planning: “The risk assessment did not outline which sling and the procedure for staff to follow when operating the hoist. This lack of information meant staff may not work in a consistent manner.”
moderateGovernance: “The provider's care plan audit was not effective. The audit had not identified that people's individual risk assessments required clearer guidance for staff to follow.”
minorRecord keeping: “Risk assessments did not always provide staff with clear guidance, including the support people needed to mobilise safely.”
Strengths
· Staff were aware of risks to people and how to manage them despite gaps in risk assessments
· Effective systems to investigate incidents and accidents with appropriate notifications to CQC and local authority safeguarding team
· People and relatives spoke highly of staff, describing them as kind, caring and respectful
· Medication administered safely with training and shadowing before sign-off
· Staff recruited safely with pre-employment and DBS checks completed
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Staffing and recruitmentGood
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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staff; Promoting a positive cultureGood
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving careGood