Queensway Homes Ltd was rated Good overall at its first inspection, with people receiving safe, effective, caring and responsive personalised care from a consistent staff team. Well-led was rated Requires Improvement due to gaps in staff file audits, missing right-to-work documentation, absence of a smoking risk assessment, and supporting people with mental health needs without updating the statement of purpose or providing mental health training.
Concerns (5)
moderateGovernance: “Systems had not identified that staff file audits were not taking place.”
moderateRecord keeping: “one staff file did not have 'right to work' documentation within it.”
moderateStaff training: “The agency was supporting people with mental health concerns without appropriate mental health training.”
moderateCare planning: “a person who smoked did not have a risk assessment in place. This meant staff may not know all the risks associated with smoking inside the property”
moderateLeadership: “They had not updated their statement of purpose to reflect this, nor had they notified the Care Quality Commission to ask for a change in user banding”
Strengths
· Medicines administered safely with staff trained and competency checked regularly
· Safe recruitment processes and thorough staff induction
· Staff knew how to recognise and report signs of abuse; people felt safe and trusted staff
· Person-centred care plans developed with involvement of people and professionals
· Staff matched to people by personality, culture and language to support feeling 'at home'
Quality-Statement breakdown (22)
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot 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
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: Staff working with other agencies to provide consistent, effective, timely careNot 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 empowering; Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated