First inspection of this newly registered domiciliary care agency rated Good overall, with people receiving safe, effective, caring and responsive personalised care from a stable, kind staff team. Well-led was rated Requires Improvement due to gaps in quality monitoring, untimely care plan/risk assessment audits, and a lack of feedback sought from relatives and people in accessible formats.
Concerns (6)
moderate
Governance
: “Audits were in place for medicines, call logs and daily logs. However, care plans and risk assessments were not always audited in a timely manner.”
moderateCare planning: “People's care plans and risk assessments were not always reviewed in a timely manner.”
moderateRecord keeping: “Risks associated with people's care and support needs had not been consistently assessed. We found no evidence of harm to people and concluded this was a recording issue.”
moderateCommunication with families: “Feedback was not sought from relatives or external healthcare professionals. Relatives told us they had not been asked for feedback and records confirmed this.”
moderateStaff training: “training required to support people with learning disabilities was not actively provided to staff.”
moderateLeadership: “The manager was unaware of specific guidance providers must follow to ensure they are meeting the principles of Right care, right support, right culture”
Strengths
· Medicines were managed safely with competency assessments and regular audits
· Sufficient staff and safe recruitment with DBS checks
· Stable core team providing continuity of care
· Staff described as kind, caring and respectful by people and relatives
· Person-centred care plans detailing preferences
Quality-Statement breakdown (20)
safe: Assessing risk, safety monitoring and management. Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot 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; 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 care; respecting 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: Engaging and involving people using the service, the public and staff; continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Duty of candour; understanding roles, quality performance, risks and regulatory requirementsNot rated
well-led: Working in partnership with othersNot rated