Ave Maria Care Services was rated Requires Improvement overall, with a breach of Regulation 17 (Good Governance) due to persistent call timing failures dating back to August 2022 that monitoring systems identified but failed to resolve. Safe, effective and caring domains were all rated Good, with staff providing consistent, respectful and knowledgeable care to the 54 people supported.
Concerns (4)
critical
Governance
— “Systems in place to assess, monitor and improve the quality and safety of the services provided were not always effective.”
moderateMissed or late visits — “call scheduled for 10 am, was made as early as 08.55 am and as late as 11.15am”
moderateComplaints handling — “complaints had been received in November and December 2022 relating to call times; therefore, we could not be assured that actions taken in response were effective in a timely manner”
moderateIncident learning — “From August 2022 to March 2023, the provider had been completing 2-weekly audits of calls times, which showed ongoing issues with calls time.”
Strengths
· Staff were knowledgeable in safeguarding adults' procedures and people felt safe with care and support of staff.
· Consistent staffing teams with people receiving care from regular, familiar staff members.
· Effective infection control procedures with good supply of PPE provided to staff.
· Staff were caring, respectful and involved people in their care and wishes.
· Pre-service assessments completed including medical history, healthcare conditions and care needs.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementGood
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: Ensuring consent to care and treatment in line with law and guidanceGood
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
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 preferencesRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Meeting people's communication needsGood
responsive: End of life care and supportNot rated
well-led: Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood