First inspection of this domiciliary care agency rated Requires Improvement overall, with breaches of Regulation 17 (good governance) and Regulation 18 (staffing) due to inadequate training, competency oversight, and unverified scope of registration for complex care tasks. Caring was rated Good with positive feedback on dignity, respect and staff kindness, but safe, effective, responsive and well-led all required improvement.
Concerns (7)
criticalStaff training — “Training statistics for some mandatory training were low and some competency assessments related to specific tasks were not in date.”
criticalStaff competency — “Two staff members were providing a specific task for a person with complex needs had not had their competency checked since 2018.”
criticalGovernance — “The provider's quality assurance processes had not identified the concerns found during the inspection in relation to staff training, skills and competencies.”
moderateLeadership — “We were not yet assured the provider who was also the registered manager had a good understanding of their role and responsibilities in relation to the conditions of their registration”
moderateMedication management — “medicine was administered to two people with complex needs in a specific way and we were not assured this was within the scope of the providers registration.”
moderateCare planning — “Two people that used the service had been receiving care without an appropriate healthcare professional providing oversight.”
minorMissed or late visits — “There was mixed feedback about late calls, however the provider had recognised this and was working on reducing this.”
Strengths
· People and their relatives told us they felt safe and were protected from the risk of abuse.
· Staff were recruited safely and there were enough staff to meet people's needs.
· People were treated with dignity and respect; care plans considered cultural, religious and spiritual needs.
· Staff monitored people's health effectively and worked well with other professionals.
· Complaints procedure was in place and complaints were investigated and resolved.
Quality-Statement breakdown (20)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: 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 to maintain a balanced dietNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot 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 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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Working in partnership with othersNot rated