FDS Divine Care Ltd received 'Requires Improvement' across all five key questions at its first inspection, with breaches of Regulation 17 (Good Governance) and Regulation 19 (Fit and Proper Persons Employed) identified. Key failures included inadequate oversight of care call monitoring, unsafe recruitment practices, basic care plans lacking person-centred detail, and failure to follow the complaints policy.
Concerns (11)
criticalGovernance: “The registered manager lacked oversight. For example, there was no audit completed to look at staff call times”
criticalStaffing levels: “The data also showed that some staff were scheduled to provide care at two different locations at the same time.”
criticalSafeguarding: “Staff were not always recruited safely. Staff files showed gaps in employment history had not always been checked.”
moderateRecord keeping: “Staff were not logging in correctly using the ECM system...one staff member was seen...to have logged in at a distance from the person's home.”
moderateStaff training: “Staff were not all up to date with training and the registered manager had not completed the additional training for managers”
moderateCare planning: “Care plans lacked detail about people's needs and choices. Care plans were basic and did not fully reflect people's needs”
moderatePerson-centred care: “People's choices, likes and dislikes were not fully reflected in their care plans...they contained information that was no longer applicable.”
moderateComplaints handling: “The complaints policy had not been followed when a complaint had been raised. There was no written response to the complainant”
moderateIncident learning: “Incidents and accidents were recorded but the action that had been taken as a result of these was not recorded to minimise the risk of reoccurring.”
minorEnd-of-life care: “Care workers and management had not received end of life training, so they were not skilled in end of life care and support if the need arose.”
minorCommunication with families: “One person's care plan stated they needed to see care worker's face/lips when communicating. The person told us staff wore face masks.”
Strengths
· People felt safe and spoke positively about the caring nature of care workers, with one person saying staff 'just seem genuine and they have got my interests at heart'.
· DBS checks had been completed for all staff.
· Staff had up-to-date safeguarding training and were confident raising concerns with their manager.
· The provider ensured people received care from a consistent small team of staff who knew them well.
· Staff had access to PPE and infection prevention and control policy was up to date.
Quality-Statement breakdown (19)
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Assessing risk, safety monitoring and management; safeguardingRequires improvement
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; care planningRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Working with other agencies; supporting access to healthcareRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in decisionsRequires improvement
responsive: Planning personalised care; choice, control and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: End of life care and supportRequires improvement
well-led: Managers and staff clear about roles; quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people, public and staff; working in partnershipRequires improvement