First inspection of a small domiciliary care agency supporting one person, rated Good overall with positive findings on safety, effectiveness, caring and responsiveness. Well-led was rated Requires Improvement due to absence of formal quality assurance systems and inconsistent record keeping, though no impact on the person's care was identified.
Concerns (3)
moderate
Governance
: “there was no formal quality assurance systems in place that these checks were on going and as the number of people using the service increased these lack of systems had the potential to mean that areas for improvement would not be identified”
moderateRecord keeping: “Records were not always clear regarding people's needs and choices”
minorCare planning: “Although staff knew people well, however records did not always reflect this. The registered manager provided assurance this would be put into place.”
Strengths
· Person felt safe with staff and appreciated the assistance provided
· Staff had received safeguarding training and understood how to report concerns
· Safe recruitment practices including DBS checks were carried out
· Staff received training relevant to their role and completed the Care Certificate during induction
· Staff respected privacy, dignity and promoted independence
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Working in partnership with othersNot rated