Passion Domiciliary Care Ltd received a second consecutive 'Requires Improvement' rating following a focused inspection of the Safe and Well-led domains, with a continued breach of Regulation 17 (Good Governance) due to failures in medicines competency oversight, equality and diversity in care planning, and diabetes-specific staff training. Despite these governance shortfalls, people and their relatives reported kind, respectful care, no missed visits, and effective safeguarding practices.
Concerns (5)
criticalGovernance: “Governance did not highlight the need for the registered manager to undertake relevant training, to deem them competent to undertake medicines competency assessments.”
criticalMedication management: “Medicine competency assessments were carried out by the registered manager who had not received any training to deem them competent to do so.”
moderateStaff training: “Staff had not received relevant training to ensure they had the skills to support people with diabetes. There was no emphasis focused on equality and diversity.”
moderateCare planning: “1 care record misrepresented a person's ethnicity. A certain part in relation to the person's personal care needs was missing in their care plan.”
moderateCultural competency: “The provider's governance did not identify the relevance of equality and diversity during the assessment and care planning.”
Strengths
· Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing.
· Staff had training on how to recognise and report abuse and they knew how to apply it.
· Recruitment procedures had been improved since the previous inspection, with all safety checks now carried out.
· The registered manager demonstrated duty of candour and was open and transparent about issues.
· The provider worked closely with other healthcare professionals and external agencies to ensure continuity of care.
Quality-Statement breakdown (12)
safe: Preventing and controlling infectionGood
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Learning lessons when things go wrongRequires improvement
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 careRequires improvement