Office NE, a domiciliary care agency in Chester Le Street, improved from Requires Improvement to Good across all five key questions, resolving previous breaches of Regulations 17 and 19. A recommendation was made to improve the recording of staff competency observations, but no regulatory breaches were identified at this inspection.
Concerns (1)
minor
Staff competency
: “records relating to staff competence required more detail in terms of what specific criteria they were being assessed against.”
Strengths
· Safe recruitment practices followed including DBS checks and references, resolving prior breach of Regulation 19.
· People received consistent care from regular staff who knew them well, with visits mostly on time.
· People and relatives spoke positively about the caring, kind and friendly nature of staff.
· Care plans were person-centred, reviewed regularly, and reflected individuals' current needs and preferences.
· Good governance improvements made, resolving prior breach of Regulation 17; regular audits and spot checks in place.
Quality-Statement breakdown (23)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; learning lessons when things go wrongGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
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
caring: Respecting and promoting people's privacy, dignity and independenceGood
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: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff; continuous learning and improving careGood
Office NE remained rated Requires Improvement following a focused inspection of Safe and Well-led, with continued breaches of Regulation 19 (Fit and Proper Persons Employed) and Regulation 17 (Good Governance). The provider had failed to submit the required action plan after the previous inspection and had not made sufficient improvements to recruitment processes.
Concerns (4)
criticalGovernance: “The provider had failed at the request of the Commission to submit a report explaining any plans that they had for improving the standard of the services provided”
criticalStaff competency: “The provider had failed to operate effective recruitment processes. Regulation 19 (2).”
moderateRecord keeping: “A reference obtained for one person did not follow the legislative requirements.”
moderateLeadership: “Systems were still either not in place or robust enough to demonstrate the service was well-led.”
Strengths
· People told us they felt safe with the carers looking after them
· Staff were appropriately trained in safeguarding to protect people from abuse
· Medicines management was undertaken in a safe manner
· Provider was using PPE effectively and safely
· Person-centred culture with consistent care staff
Quality-Statement breakdown (12)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering