First inspection of this small domiciliary care agency rated Good across all five key questions, with safe medicines management, safeguarding, recruitment and person-centred care all well evidenced. Minor improvements were identified around formalising staff supervision, spot checks, complaints audits and communication systems, all addressed during or immediately after the inspection.
Concerns (4)
minor
Supervision / appraisal
: “staff supervision sessions were in the process of being implemented”
minorCommunication with families: “one relative felt staff could be more assertive in meeting their loved one's needs, as the person often refused care agreed in their care plan”
minorGovernance: “An overview and monthly audit was implemented following the inspection to ensure any themes or trends would be picked up.”
minorStaff competency: “Regular spot checks were completed to ensure staff were adhering to all requirements. These were made more formal following the inspection”
Strengths
· Safe medicines management with appropriate policy and training
· Robust safeguarding systems and staff training
· Thorough risk assessments reviewed regularly
· Safe recruitment with appropriate documentation
· No missed visits and staff stayed required length of time
Quality-Statement breakdown (23)
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: 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 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
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: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated