The Health Care Group (THCG) Ltd was rated Good overall at its first comprehensive inspection, with Effective rated Requires Improvement due to inconsistent application of the Mental Capacity Act around recording specific decisions and best interests meetings. People received safe, caring, responsive and well-led care, though minor issues were identified with employment-history records and an out-of-date complaints policy.
Concerns (4)
moderate
Consent / capacity
: “The provider assessed their capacity but did not always record the specific decision being assessed, with specific best interests decision meetings, in line with the Act.”
moderateRecord keeping: “some staff files lacked a fully explored and recorded employment history which meant the provider might not have fully verified the suitability of the staff.”
minorComplaints handling: “The complaints policy was not fully up to date and required updating to direct people to the Ombudsman if necessary, not CQC, as they do not investigate individual complaints.”
minorStaffing levels: “the registered manager told us recruitment had been difficult and this is ongoing. The provider was recruiting staff from overseas so they could care for more people.”
Strengths
· Medicines managed safely with electronic real-time oversight and competency-checked staff
· Consistency of care from a small number of staff who knew people well
· Staff treated people with kindness, dignity and respect; people praised carers
· Personalised care plans reflecting people's backgrounds, preferences and cultural needs
· Regular training, supervision, appraisal and spot checks for staff
Quality-Statement breakdown (18)
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot 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
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: Continuous learning and improving care; Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Engaging and involving people; Working in partnership with others; Duty of candourNot rated