Black and White Group Limited, a small domiciliary care service in Gloucester, was rated Good overall at its first CQC inspection in January 2021, with four of five key questions rated Good. Well-led was rated Requires Improvement due to inconsistencies in governance, record-keeping, staff recruitment documentation, and communication systems, with a recommendation to review quality assurance processes.
Concerns (5)
moderate
Governance
: “we found some inconsistencies and discrepancies in the culture and style of the management...inconsistencies in the records of delivery of care and the systems to communicate the well-being of people”
moderateRecord keeping: “Further improvement was needed in the quality of the records of staff recruitment, induction and spot checks of staff to demonstrate that staff had been safely recruited”
moderateCommunication with families: “Some staff felt they were not always confident in reporting concerns to the management team.”
minorStaff training: “The registered manager stated that they planned to improve the recording of probation meetings and observations of staff as well as incorporating the Care Certificate into the induction programme.”
minorSupervision / appraisal: “the registered manager had started to roll out a schedule of supervision meetings with staff in line with their staff development policy.”
Strengths
· People and relatives felt safe and spoke positively about the caring nature of staff.
· Safe medicines management practices were in place, with no gaps in medicines administration records and regular audits by the registered manager.
· People were supported by small, consistent staff teams promoting continuity of care.
· Care plans were person-centred, detailed and regularly reviewed, reflecting people's preferences and choices.
· The provider and registered manager were passionate about delivering quality care and open to learning and improvement.
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candour; managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; working in partnership with othersGood