365 Divine Care improved from Requires Improvement to Good across all inspected key questions (safe, effective, responsive, well-led), having resolved all prior breaches of regulations 12 and 18. The service demonstrated strengthened risk assessment, medicines management, staff training, person-centred care planning, and quality assurance processes since the last inspection in June 2021.
Strengths
· Provider resolved all previous breaches of regulation 12 (safe care and treatment) and regulation 18 (staffing) found at last inspection
· Robust recruitment procedures with comprehensive staff files including DBS checks, right to work, and interview notes
· Medicines management systems improved to safe standard with supervisor/manager checks for accuracy
· Risk assessments reviewed and fully completed with detailed management plans including moving and handling guidance
· Staff receive regular supervision, annual appraisals, face-to-face and e-learning training including medicines and safeguarding
Quality-Statement breakdown (18)
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 infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
responsive: Meeting people's communication needsGood
responsive: Planning personalised care to ensure people have choice and control; 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 requirements; Continuous learning and improving careGood
well-led: How the provider understands and acts on the duty of candour; Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood