Creative Support – Tameside Domiciliary Service was rated Requires Improvement across all five key questions following an October 2018 inspection, with warning notices issued for breaches of Regulations 12 and 17 relating to unsafe medicines management and inadequate governance. Key failures included incomplete risk assessments, lack of mental capacity assessments, non-person-centred care plans, unsafe recruitment, and persistent late and shortened care calls.
Concerns (11)
criticalMedication management: “Medication administration records (MAR) were intermittently signed...Charts did not always have the full name, date of birth and allergies recorded.”
criticalMissed or late visits: “One person who received a 45-minute daily morning call received only 15 minutes care on each visit over three mornings.”
criticalCare planning: “Care plans in the community did not fully give guidance to staff to effectively support people and did not highlight important information.”
criticalConsent / capacity: “The registered manager told us that no one being supported by the service had undergone a capacity assessment by Creative Support.”
criticalRecord keeping: “A person...did not have documented there was a percutaneous endoscopic gastrostomy (PEG) in situ...same person was described as 'Nil by mouth'. This was not recorded.”
criticalGovernance: “Audits of medicines were completed monthly but did not identify errors on the MAR such as people's names and allergies not being recorded.”
criticalSafeguarding: “One staff member had received a disclosure and barring service check (DBS) three weeks after their start date...no evidence the staff member had shadowed more experienced staff.”
moderateStaffing levels: “The inconsistency of regular staffing to support people was a common theme...people did not always receive a core group of staff members.”
moderateSupervision / appraisal: “Staff told us they received supervision and appraisal, but we found the records lacked content and many of the sections were blank.”
moderatePerson-centred care: “One-page profiles for people in the community were not personalised and held limited information.”
minorCultural competency: “Religious or cultural needs were not always recorded in peoples care plans.”
Strengths
· Staff were kind, respectful and supportive of people's independence, with many people highly complimentary of regular carers.
· Safeguarding training was in place and staff could clearly describe signs of abuse and reporting responsibilities.
· Accidents and incidents were documented and analysed to prevent future occurrences, with information shared for wider learning.
· Complaints were responded to in a timely manner with a complaints policy and log in place.
· Extra care service had more robust care plans, risk assessments and medication management.
Creative Support - Tameside Domiciliary Service achieved a Good rating across all five key questions at this May 2021 inspection, having improved from Requires Improvement and remediated all previous regulatory breaches. The service demonstrated safe care, effective governance under a new registered manager, and consistently high satisfaction among the 138 people it supported.
Strengths
· Risks to individuals were identified and well managed, with care records clearly explaining how to keep people safe.
· Medicines were administered safely with robust records, risk assessments, and regular staff competency checks.
· Safe recruitment systems were in place with all required pre-employment checks completed.
· Staff received comprehensive induction, mandatory training, and regular supervision with very positive feedback.
· People received highly personalised, person-centred care respecting their needs, wishes, and preferences.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infection; Learning lessons when things go wrongGood
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 experience
Good
effective: Supporting people to eat and drink enough; access healthcare services; staff working with other agenciesGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships; end of life care and supportGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candour; Continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staffGood