Five Star Support, a small domiciliary care agency supporting 13 people with physical disabilities, learning disabilities and autism, improved from Requires Improvement to Good overall, resolving a previous breach of Regulation 18 around supervision and appraisal. Minor issues remained around recording consent, staff recruitment history gaps and audit checks, all addressed during the inspection.
Concerns (3)
minorConsent / capacity: “Not all people had signed their care plans to consent to care. We found one care plan outlined the person had capacity to consent, however, their care plan had been signed by staff and a relative.”
minor
Record keeping
: “Whilst we did identify unexplored gaps in staff members' employment history, the registered manager was able to produce this information during the site visit.”
minorGovernance: “We discussed with the registered manager how existing checks on people's daily logs, medication administration records (MAR) and staff recruitment could be further improved.”
Strengths
· Person-centred care records clearly outlining support needs
· Consistent staff team who knew people well
· Safe medication management with PRN protocols and competency checks
· Strong safeguarding awareness and prompt escalation of concerns
· Improved supervisions, spot checks and personal development plans (previous breach of Regulation 18 resolved)
Quality-Statement breakdown (16)
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
well-led: Promoting a positive, person-centred cultureNot rated
well-led: Duty of candour and opennessNot rated
well-led: Managers and staff understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people, public and staff; continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated