Lily of the Valley Care, a small domiciliary care service supporting 21 people, was rated Good overall at its first inspection, with Effective rated Requires Improvement due to missing mental capacity assessments. Two safeguarding incidents had not been referred to the local authority and audits had not identified these gaps, but the provider took immediate action and the service demonstrated a caring, person-centred culture.
Concerns (3)
moderate
Safeguarding
: “two incidents we looked at, had not been recognised by the provider as possible abuse... these should have been referred to the local authority safeguarding team”
moderateConsent / capacity: “no capacity assessments had been completed where needed. However, this had not impacted on the support they received to make decisions.”
moderateGovernance: “Audits had not identified gaps regarding mental capacity assessments and incidents that should be referred to the local authority safeguarding team.”
Strengths
· Staff received training and competency checks for safe medicines management with recent audits in place
· People and relatives spoke highly of the kind, caring and respectful staff team
· Regular team of staff providing consistency, with robust pre-employment checks completed
· Extensive training programme including specialist training such as PEG feeding and end of life care
· Open, person-centred culture with approachable management and active engagement with people, relatives and staff
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot 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: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; supporting people to access healthcareNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversity; privacy, dignity and independenceNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot 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: Supporting people to develop and maintain relationships to avoid social isolationNot 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, understanding quality performance, risks and regulatory requirements; promoting a positive person-centred cultureNot rated
well-led: Engaging and involving people, the public and staff; duty of candourNot rated
well-led: Continuous learning and improving care; working in partnership with othersNot rated