Standon Gardens Domiciliary Services was rated Requires Improvement overall, with breaches in Regulation 17 (Good Governance) due to ineffective quality assurance systems, unsafe medicines management, and incomplete care records and risk assessments. Caring, effective, and responsive domains were rated Good, reflecting compassionate, person-centred care delivery by a consistent and well-regarded staff team.
Concerns (8)
critical
Medication management
: “One person was prescribed two tablets to be given at the same time for two of their medicines, but staff were recording only one tablet was being given of each medicine.”
criticalGovernance: “Quality assurance systems were not fully effective and embedded to ensure the quality and safety of care was monitored. Breach of Regulation 17: Good governance.”
moderateMedication management: “Medicines which were noted as 'when required', also known as PRN medicines, did not have PRN protocols in place to guide staff when the medicine may be needed.”
moderateRecord keeping: “Actual call times when staff attended were not recorded and the specific details of the calls were not recorded.”
moderateCare planning: “Other records we viewed for other people did not always have sufficient details, missing information and no risk mitigation details.”
moderateGovernance: “The operations manager had a basic action plan in place. They acknowledged it was not detailed as they felt their plans were mainly in their head.”
moderateLeadership: “The registered manager had been open and honest with us and had explained they had not been very involved with the service and had not been fulfilling the registered manager role.”
minorConsent / capacity: “The operations manager told us they checked people's LPOAs. However, the evidence of these checks was not provided to us as part of the inspection.”
Strengths
· People felt safe and staff knew people well, with consistent staffing and generally good time-keeping reported by people and relatives.
· Staff demonstrated kind, compassionate, and dignified care, treating people as individuals and supporting their independence.
· People were involved in developing their care plans and had regular reviews, receiving personalised care aligned to their preferences.
· Staff understood safeguarding responsibilities and infection prevention and control measures were effective.
· People and relatives felt able to raise complaints and feedback was acted upon promptly.
Quality-Statement breakdown (24)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Continuous learning and improving care; Working in partnership with othersRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood