FACT Healthcare Ltd was rated Good overall at its first CQC inspection in May 2017, with safe, effective, caring and responsive care delivered by consistent, well-regarded staff to a small number of people. The Well-Led domain was rated Requires Improvement due to gaps in recruitment records and insufficient documentation of staff induction completion via the care certificate.
Concerns (3)
moderate
Record keeping
: “in three of the five staff files we found both gaps in their employment history or a lack of a full employment history”
moderateRecord keeping: “records provided to care staff to show their understanding and completion of the care certificate were lacking”
moderateGovernance: “the providers systems in terms of record keeping in relation to recruitment and completion of a comprehensive induction were not robust”
Strengths
· People felt safe with care staff and risks were clearly assessed and documented in care records
· Consistent care staff allocation gave people continuity and familiarity with their individual needs
· Care staff demonstrated good knowledge of safeguarding procedures and whistleblowing policy
· People's consent was sought before care was provided, in line with MCA principles
· Care was person-centred, dignified and respectful, with people involved in decision-making
Quality-Statement breakdown (14)
safe: Safeguarding and risk assessmentGood
safe: Staffing levels and consistencyGood
safe: Recruitment practicesRequires improvement
effective: Staff induction, training and supervisionGood
effective: Mental Capacity Act complianceGood
effective: Nutrition and healthcare accessGood
caring: Dignity, respect and person-centred approachGood
caring: Involvement in decisions and promoting independenceGood
responsive: Personalised care planningGood
responsive: Complaints handlingGood
responsive: Cultural and diverse needsGood
well-led: Record keeping and governance systemsRequires improvement
well-led: Leadership, culture and continuous improvementGood