180 Surrey Street is a small domiciliary care agency rated Good across all five key questions at its first comprehensive inspection in March 2019. The service demonstrated safe, person-centred care with strong leadership, though minor gaps were noted in staff equipment training and formal quality surveying.
Concerns (3)
minor
Staff training
: “One person was unsure about the training staff received. They told us staff did not understand technical aspects of special equipment they used and this had caused problems.”
minorCare planning: “Not all people using the service were fully aware of who they could complain to.”
minorGovernance: “The registered manager told us they have not yet carried out a formal quality survey amongst people using the service but planned to do this in the next few months.”
Strengths
· People and relatives provided consistently positive feedback about care, staff and management.
· Robust safeguarding policies and staff understanding of responsibilities to protect people from abuse.
· Thorough recruitment procedures including DBS checks and references to ensure suitable staff.
· Staff received regular supervision and felt well supported by the registered manager.
· Person-centred care plans reflected individual needs, preferences, routines and communication needs.
180 Surrey Street is a domiciliary care agency registered to provide personal care. The assessment was carried out due to information of concern received about the service. We also checked whether the service had made improvements since our last inspection. The assessment was completed remotely by an assessor, an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. We received feedback from the local authority quality monitoring team. During the assessment process we spoke with 2 people using the service and 6 relatives and friends. We looked at eight quality statements: [Learning culture, Safe systems, pathways and transitions, Safeguarding, Involving people to manage risks, Safe and effective staffing, Medicines Optimisation, Capable, compassionate and inclusive leaders, Freedom to speak up, Governance, management and sustainability and Learning, improvement and innovation]. At our last inspection the service was rated requires improvement. At this assessment we found the provider had made some improvements to meet the regulations. However, further action was required. The service rating remains requires improvement. At our last inspection the service was in breach of the regulations around governance due to a lack of robust systems to effectively monitor and improve the service. The provider had not made enough improvements in this area and continued to be in breach of this regulation.
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Focused inspection downgraded the service from Good to Requires Improvement, with a breach of Regulation 17 due to inadequate governance, inconsistent risk assessments, missing MAR signatures and ineffective monitoring of care calls. Staff were viewed positively by people and worked safely with external professionals, but oversight failures placed people at potential risk of harm.
Concerns (9)
criticalGovernance: “The providers governance audits and checks had not been consistently completed at the frequency the provider had stated they were required.”
moderateMedication management: “Medicine administration records for three people during March 2022 showed missing staff signatures.”
moderateMissed or late visits: “There was no evidence care calls were being effectively reviewed and monitored to ensure people received their care as expected and assessed for.”
moderateCare planning: “Guidance for staff about how to manage and mitigate risks to protect people was inconsistent.”
moderateRecord keeping: “A recent complaint about a missed call had not been logged. The registered manager post inspection advised this was an oversight.”
moderateStaffing levels: “on two occasions, one care staff member attended a call when this should have been two care staff.”
minorComplaints handling: “The complaints log had not been kept up to date.”
minorInfection control: “some relatives told us how staff would at times, wear their face mask under their chin or not at all.”
minorCommunication with families: “We received a mixed response about people's experience of being advised if care staff were running late.”
Strengths
· Staff aware of safeguarding responsibilities and had received safeguarding training
· People reported feeling safe and positive about staff competency and approach
· Robust recruitment checks including criminal records and references completed before staff commenced
· Systems and processes to record, investigate and monitor incidents and accidents for learning
· Staff felt well supported, valued and listened to by the management team
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
well-led: Governance, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Duty of candour and open cultureRequires improvement