Yorkshire and Humber Healthcare Alliance LLP was rated Good overall at its first CQC inspection, with safe, effective, caring and responsive domains all Good, but Well-led was Requires Improvement due to the absence of a registered manager and incomplete audit documentation. No breaches of regulation were cited beyond the registration condition, and the provider demonstrated a commitment to improvement.
Concerns (3)
critical
Governance
: “The service did not have a registered manager in place and were therefore not compliant with the conditions of registration.”
moderateRecord keeping: “Some of the audit checks had not been documented such as medicines and care plan audits. This made it difficult to review what the service was looking for.”
minorSupervision / appraisal: “One staff's records we saw had no documented supervision records. The provider told us they had been supported but the documentation was missing.”
Strengths
· Medicines administration records were fully completed, regularly returned and management checks completed; staff competency in medicines observed regularly.
· Risk assessments were detailed, up to date and provided staff with clear guidance on mitigating known risks.
· Safe recruitment procedures in place including DBS checks and reference checks prior to staff starting.
· Care plans were personalised, detailed and reflected people's cultural backgrounds, preferences and specific health conditions.
· People felt safe with their care workers and received calls at agreed times from familiar staff.
Quality-Statement breakdown (18)
safe: Risk managementGood
safe: Medication managementGood
safe: SafeguardingGood
safe: Staffing levels and recruitmentGood
safe: Infection controlGood
effective: Staff training and inductionGood
effective: Supervision and competency checksGood
effective: Mental Capacity Act and consentGood
effective: Nutritional support and health care accessGood
caring: Person-centred approach and dignityGood
caring: Involvement in care planningGood
caring: Promotion of independenceGood
responsive: Personalised care planningGood
responsive: Timeliness of care callsGood
responsive: Complaints handlingGood
well-led: Registered manager in postRequires improvement