First inspection of a newly registered domiciliary care agency found one breach of Regulation 17 (Good governance), with shortfalls in medicines management, risk assessment, care planning, MCA compliance and oversight of complaints. The service was rated Good for caring, with kind staff and consistent care workers, but Requires Improvement overall pending embedded improvements.
Concerns (14)
critical
Medication management
: “MARs had not always been completed to confirm staff had administered people's medicines as prescribed... those records were not reviewed or checked by managers.”
criticalMedication management: “Guidance to inform staff when 'as required' medicines needed to be given was not in place. That meant people could have been given too much or not enough of their medicines.”
criticalGovernance: “The provider had failed to operate effective governance systems. For example, audits of care records and risk management plans had not identified the shortfalls we found.”
moderateCare planning: “The amount of information contained within people's care records varied. Some care records focussed on the tasks staff needed to complete.”
moderateConsent / capacity: “mental capacity assessments had not been completed when required to determine if people could make their own decisions to ensure their rights were upheld.”
moderateInfection control: “Risks associated with COVID-19 had not always been assessed in line with the providers policy and national guidance.”
moderateIncident learning: “the provider did not have an effective system in place to monitor, manage and reflect on incidents to prevent reoccurrence.”
moderateComplaints handling: “five complaints had been received about late calls in the 12 months prior to our visit. This indicated opportunities to identify where quality could have been improved had been missed.”
moderateRecord keeping: “Risk management plans did not always contain the information staff needed to provide safe care.”
moderateLeadership: “The service did not have a manager registered with the Care Quality Commission in line with the requirements of the provider's registration.”
minorStaff training: “Training records we viewed were not up to date and one staff member was not listed on the providers training matrix.”
minorMissed or late visits: “It was a bit chaotic with timings over the summer, staff did turn up but not always on time. I think they [staff] had too many people to look after.”
minorCommunication with families: “People's communication needs, and preferences were not always assessed or documented to help staff communicate with people well.”
minorCultural competency: “assessments needed to be further developed to ensure protected characteristics under the Equality Act 2010 including people's cultural needs were fully considered.”
Strengths
· People felt safe with their care workers and safeguarding procedures protected people from harm.
· Staff were recruited safely following safe recruitment procedures.
· People received care from a small number of consistent staff who they knew and trusted.
· Staff were kind, caring and respected people's privacy, dignity and independence.
· Staff felt supported, enjoyed their jobs and found managers approachable.
Quality-Statement breakdown (19)
safe: Using medicines safelyNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot 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; access healthcare; working with other agenciesNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and controlNot 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: Managers and staff being clear about their roles; quality, risks and regulatory requirements; duty of candourNot rated
well-led: Promoting a positive culture; engaging and involving people, public and staffNot rated
well-led: Working in partnership with othersNot rated