Divine Health Services, a domiciliary care agency supporting 23 people, was rated Requires Improvement overall due to weaknesses in safe recruitment of overseas staff and governance failures including not notifying CQC of an office move and not returning the PIR. Effective, caring and responsive domains were rated Good, with improvements noted in call timing and care plan reviews.
Concerns (6)
moderate
Staff training
— “We found where staff had come directly from overseas into their role, a DBS had not been completed.”
moderateGovernance — “The provider had not notified us of this change, and further prompting had been required.”
moderateRecord keeping — “We also found in two records only one reference had been supplied, instead of the required two references.”
moderateGovernance — “The PIR request was sent to the provider on 21 June 2021. No completed PIR was returned to the Care Quality Commission.”
moderateLeadership — “the registered manager who was also the provider did not fully understand the recruitment process for staff who came to work from overseas”
minorCultural competency — “some staff needed further support to understand the culture differences with food... one person told us they were given a knife and folk to eat their toast.”
Strengths
· People felt safe and supported by kind, familiar staff with no missed calls reported
· Care plans accurately reflected needs and were regularly reviewed with people involved
· Staff completed Care Certificate with comprehensive induction and ongoing competency checks
· Improvements made to bedtime call times via new computerised monitoring system
· Positive feedback about registered manager from people, relatives and staff
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and management; Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; supporting people to access healthcareNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and controlNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Continuous learning and improving care; engaging and involving people; working in partnershipNot rated