Body&Soul Assistance, Admin received an overall rating of Requires Improvement following a focused inspection of Safe and Well-Led, with Well-Led rated Inadequate due to breaches of Regulations 17 and 19 related to absent governance systems, poor record keeping, and unsafe recruitment practices. The single person using the service reported positive experiences of person-centred care, but systemic leadership and oversight failures presented significant risks.
Concerns (8)
criticalGovernance: “there was no evidence that audits for any part of the service had taken place, including actions to ensure staff were safely recruited.”
criticalRecord keeping: “We found widespread lack in record keeping that should be in place to make sure people's care was appropriate.”
critical
Care planning
: “The care plan we reviewed was basic and there was no evidence this had been reviewed or updated. Staff told us they did not have access to written care plans or risk assessments.”
criticalLeadership: “The provider did not have an effective management structure. The provider did not monitor the quality of care provided in order to drive improvements.”
criticalStaffing levels: “Recruitment processes were not robust to ensure staff were suitable to work. This was a breach of regulation 19 of the Health and Social Care Act 2008.”
moderateStaff training: “not all staff had received safeguarding training in line with best practice guidance and some were unclear on their safeguarding responsibilities.”
moderateSafeguarding: “not all staff had received safeguarding training in line with best practice guidance and some were unclear on their safeguarding responsibilities.”
moderateIncident learning: “The provider had not consistently created a learning culture at the service which meant people's care did not always improve. However, there were no recording systems to support this.”
Strengths
· The person in receipt of services told us they felt safe, staff kept them safe and there were sufficient staff to meet all their needs.
· People were supported to receive their medicines safely, with spot checks ensuring staff competency in medication administration.
· Staff were following safe infection prevention and control practices.
· The provider was working in line with the Mental Capacity Act; the person was offered choices and supported to make everyday decisions.
· The person in receipt of services told us they received person-centred care, meeting all their needs, with a positive and open culture.
Body & Soul Assistance is a small domiciliary care agency rated Good across all five key questions at its first inspection, providing highly personalised 24-hour care to a single person who is also the registered manager. Minor gaps were noted in formal documentation of supervisions, staff meetings, spot checks, and audit processes, though these were attributed to the unique and very small nature of the service.
Concerns (4)
minorRecord keeping: “Spot checks were carried out on an on-going basis although these were not documented. Staff meetings were held as required, but mainly on an individual basis.”
minorSupervision / appraisal: “Although there was not a formal plan of supervision and appraisal, the registered manager and staff told us this was a continuous process.”
minorGovernance: “There was no current documented audit process in place but the provider was aware of the need to implement this if the service grew.”
minorRecord keeping: “We noted one person had no photo ID and only one reference documented in their staff file.”
Strengths
· Person receiving care expressed high satisfaction: 'It is like a surrogate family' and 'Staff don't just do tasks'
· Individualised, person-centred care plans with strong emphasis on maintaining independence and personal preferences
· Registered manager held 'train the trainer' certification for moving and handling; continuous on-the-spot training provided
· Proactive approach to health management resulted in no hospital admissions in over 18 years
· Staff morale was high with staff describing the registered manager as 'brilliant support', 'knowledgeable', 'approachable' and 'empathetic'
Quality-Statement breakdown (17)
safe: Medicines managementGood
safe: SafeguardingGood
safe: Risk assessmentsGood
safe: Staffing levelsGood
safe: Recruitment proceduresGood
effective: Mental Capacity Act complianceGood
effective: Staff trainingGood
effective: Supervision and appraisalGood
Nutrition and health care support
effective:
Good
caring: Dignity and respectGood
caring: Person-centred support and independenceGood