M&N Healthcare Edgbaston, a sole-provider domiciliary care agency serving 3 people, improved from Requires Improvement to Good across Safe, Effective, and Well-led domains, resolving its prior breach of Regulation 12. Minor weaknesses remained in care plan and risk assessment detail, though the provider responded immediately to feedback during the inspection.
Concerns (3)
moderateCare planning: “care plans did not provide enough information for any agency or new staff to support people safely”
moderate
Record keeping
: “1 person's falls risk assessment just stated, 'needs support to bathroom'... some risk assessments were very basic”
moderateGovernance: “Robust auditing had not taken place and had not identified that care plans did not provide enough information”
Strengths
· People felt safe and trusted the provider; provider knew how to support people to keep them safe
· Provider worked within the principles of the Mental Capacity Act and best interests assessments
· Incidents and accidents managed effectively with lessons learned documented
· Provider worked cooperatively with GPs, community nurses, opticians and chiropodists
· Person-centred culture with dignity, respect and promotion of independence
Quality-Statement breakdown (16)
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: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood