Joelma Limited received a Requires Improvement rating following a focused inspection of Safe and Well-led domains, with a regulatory breach identified under Regulation 12 for inadequate risk assessments, unsafe medicines processes, and gaps in recruitment records. Governance and audit systems failed to identify these issues proactively, though leadership culture and staff practice were generally positive.
Concerns (8)
criticalCare planning: “Risk assessments did not always include enough information for staff about people's known areas of risk.”
criticalMedication management: “Medicine administration records (MAR) contained gaps which were not picked up during audits.”
critical
Medication management
: “There was no guidance for staff to follow when people had medicines to be taken 'as required.'”
criticalRecord keeping: “When people made a decision about DNACPR...this information was not stated in their care plan.”
moderateStaff competency: “Staff files we looked at contained gaps in staff employment histories and the reasons were not explored during the recruitment process.”
moderateConsent / capacity: “MCA assessments were not carried out to document people's decision making abilities or any support they needed in this area.”
moderateGovernance: “Audits of care records did not pick up the concerns we found about the lack of information and guidance for staff.”
minorSupervision / appraisal: “Staff also received one to one supervision sessions which were scheduled 6 monthly. The registered manager agreed more regularly was likely to be beneficial.”
Strengths
· Staff were reliable, usually arrived on time and stayed for the full length of the scheduled visit.
· People and relatives told us people felt safe with the care and support provided.
· Staff used personal protective equipment (PPE) including gloves and aprons when supporting people with personal care.
· Processes were in place for the reporting and follow up of any accidents or incidents.
· The registered manager was committed to ensuring people received good quality care and received largely positive feedback from people, relatives and staff.
Quality-Statement breakdown (13)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
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 candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood
Joelma Limited, a small domiciliary care agency in Luton supporting five people, achieved a Good rating across all five key questions at its first CQC inspection in April 2019. The service demonstrated strong person-centred care, effective governance, and responsive leadership, with only minor documentation gaps identified in risk assessments and care records.
Concerns (3)
minorCare planning: “care plans did not include people's personal history to enable staff to have a better understanding of the person. The registered manager told us they would add this.”
minorRecord keeping: “We suggested that more personalised information such as, people's emotions, interactions and outcomes would further develop these records.”
minorCare planning: “information was not as detailed for 'how' staff should safely manage the risk and recommended the risk assessments had more detailed information added in this area.”
Strengths
· People and relatives consistently reported feeling safe and that staff were kind, caring and respectful.
· The registered manager conducted thorough initial assessments covering all aspects of choice, preferences, beliefs, health and wellbeing.
· Robust recruitment processes including criminal record checks, references, shadowing and competency checks were in place.
· Effective infection control practices with staff demonstrating clear understanding of hand hygiene and PPE use.
· Lessons learned from incidents and external developments were shared proactively with staff in meetings and supervisions.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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 meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Planning and promoting person-centred, high-quality care and openness; duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood