Alicelyn Healthcare Ltd, a small domiciliary care agency supporting 10 people, was rated Good overall at its first inspection, with people reporting safe, kind, punctual and person-centred care from a highly involved nurse-led management team. Well-led was rated Requires Improvement due to basic audit systems, gaps in monitoring of records and care files, weak staffing contingency plans and incomplete recording of care review discussions.
Concerns (5)
moderate
Governance
— “the provider's systems of governance were not comprehensive, and some key quality and safety checks had not yet been established.”
moderateGovernance — “there was no clear systems in place to monitor the quality and safety of daily records, staff files and care files.”
moderateStaffing levels — “The provider's staffing contingency plans were not robust... current arrangements left almost no margin to cover unplanned absences.”
minorRecord keeping — “discussions with people and their relatives about their care and support should be recorded.”
minorMedication management — “there had been one medication error since the service began operating. We saw staff had taken appropriate action to keep this person safe, and no harm had been sustained.”
Strengths
· People felt safe and reported staff were kind and arrived on time, with good continuity from a core staff group
· Highly trained management team (registered nurses) involved directly in care delivery, providing strong oversight
· Person-centred care plans with people and relatives fully involved in decisions about their care
· Safe recruitment processes and staff trained in safeguarding, medicines and infection control
· Staff followed correct infection control procedures with good stocks of PPE
Quality-Statement breakdown (17)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Using medicines safelyNot 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; supporting people to access healthcare servicesNot 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; respecting privacy, dignity and independenceNot rated
responsive: Planning personalised care; End of life care and supportNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Managers and staff being clear about their roles; understanding quality, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture; Working in partnership with others; Engaging and involving people using the serviceNot rated
well-led: How the provider understands and acts on the duty of candourNot rated