25 The Beeches is a small domiciliary care agency rated Good overall at its first inspection, with strengths in safeguarding, person-centred care, staff support and medicines management. A Requires Improvement rating for Well-Led reflects gaps in risk assessment detail, incomplete recruitment records and insufficiently formalised quality assurance processes.
Concerns (3)
moderate
Care planning
: “Risk assessments had been completed and regularly reviewed however they did not always contain detailed guidance for staff to follow.”
moderateRecord keeping: “Staff did not always have a full employment history documented.”
moderateGovernance: “Quality checks were undertaken by the registered manager however were not always formerly recorded or had not identified the concerns we found.”
Strengths
· People were supported by a consistent team of staff who knew them well and no missed care call visits were experienced.
· Staff had completed safeguarding training and could describe actions to take if concerns were identified.
· Relatives spoke positively about staff being kind, caring and going above and beyond, with all saying they would recommend the service.
· Staff received induction, Care Certificate training, supervisions and ongoing support from an approachable registered manager.
· Medicines management included staff training, competency assessments and regular audits by the registered manager.
Quality-Statement breakdown (22)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to live healthier lives and access healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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: 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, understanding quality performance, risks and regulatory requirementsRequires 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
well-led: Continuous learning and improving care; working in partnership with othersGood