First inspection of this domiciliary care agency rated Requires Improvement overall, with breaches of regulations 17 (good governance) and 19 (fit and proper persons) due to weak recruitment checks, gaps in medicines and risk records, and limited oversight of visits. Caring, effective and responsive domains were rated Good, with positive feedback on staff approach, person-centred support and consistent visits.
Concerns (9)
critical
Governance
: “Audits and quality checks were in place, although were not robust enough to identify and act upon areas to improve, such as care records, risk assessments and gaps in medication records.”
criticalStaff competency: “One member of staff's application form did not correlate with their completed DBS check and another member of staff worked at the service prior to one reference being received.”
moderateMedication management: “Medicines were not always recorded thoroughly and there were gaps in documentation.”
moderateCare planning: “Risk assessments were not always in place or lacked information where people had specific health conditions, such as diabetes.”
moderateStaff training: “Regular training was recorded on the training matrix, although face to face training had not been provided and the provider said this was due to the COVID-19 pandemic restrictions.”
moderateRecord keeping: “COVID-19 testing was regular, although recording of staff tests was not completed.”
moderateMissed or late visits: “The management team had no formal means of monitoring staff calls, how long staff stayed at each visit, and whether they arrived safely.”
minorSupervision / appraisal: “Staff gave us mixed views about their induction, training and supervision; some staff said they were fully prepared for their role and had enough training and support, whilst other staff gave contrasting information.”
minorComplaints handling: “The management team maintained a record of complaints which showed these were attended to, although the outcomes were not always fully recorded.”
Strengths
· Consistent and reliable staffing with people feeling safely supported
· Staff used PPE consistently and infection prevention measures were known
· Caring, person-centred approach with staff respecting privacy, dignity and independence
· People and relatives involved in agreeing and reviewing care plans
· Safeguarding procedures were clear and understood by staff
Quality-Statement breakdown (16)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and management; Using medicines safelyNot rated
safe: Learning lessons when things go wrongNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
effective: Staff support: induction, training, skills and experience; Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Supporting people to eat and drink enough; staff working with other agencies; supporting people to access healthcareNot 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 diversity; supporting people to express their viewsNot 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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staff; working in partnership with othersNot rated