First inspection of newly registered domiciliary care agency rated Requires Improvement overall, with a breach of Regulation 18 for failing to notify CQC of a safeguarding incident. Care delivery, safety and staff training were rated Good, but complaints handling, governance and leadership consistency required improvement.
Concerns (7)
critical
Safeguarding
: “we identified a safeguarding incident, an allegation of abuse, which had not been reported to the Care Quality Commission (CQC) in line with guidance”
criticalGovernance: “The provider failed to notify the CQC without delay of a notifiable incident. This is a breach of Regulation 18”
moderateComplaints handling: “Complaints had not been consistently managed in a professional and transparent manner. People had not always received an apology when something could have been done better.”
moderateIncident learning: “The complaint was not initially responded to in a candid and professional manner and was not fully investigated in the first instance.”
moderateCare planning: “it was found there was no evidence of a needs assessment having been completed, in line with the provider's processes, before a person began to use the service”
moderateLeadership: “the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”
minorSupervision / appraisal: “Staff supervision meetings had lapsed during the COVID-19 pandemic. However, these had recommenced, and a schedule of meetings was in place.”
Strengths
· People supported by regular staff who arrived on time and stayed the correct length of time
· Safe recruitment with DBS checks, references and full employment history
· Medicines administered as prescribed via electronic system with alerts
· Staff completed Care Certificate, regular training and competency checks
· Person-centred care plans recording life history, cultural and spiritual needs
Quality-Statement breakdown (20)
safe: Staffing and recruitmentNot rated
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: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot 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
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: Improving care quality in response to complaints or concernsNot rated
responsive: Planning personalised care to ensure people have choice and controlNot rated
responsive: Meeting people's communication needsNot rated
responsive: End of life care and supportNot rated
well-led: Duty of candour; understanding quality, risks and regulatory requirements; continuous learningNot rated
well-led: Promoting a positive, person-centred, open and inclusive cultureNot rated
well-led: Engaging and involving people, public and staff; working in partnershipNot rated