First inspection of this newly registered domiciliary care service rated Good overall and across all five key questions, with people and relatives reporting safe, kind and personalised care from a well-supported staff team. Three recommendations were made regarding risk assessment detail, support planning and the effectiveness of quality assurance audits, and the registered manager responded promptly to address these gaps.
Concerns (5)
moderate
Record keeping
: “Records did not always include enough detail on how risks should be managed and mitigated. For example, falls risks, risks relating to diabetes and allergies.”
moderateGovernance: “Audits had not always identified the gaps and omissions in paperwork we found during the inspection.”
minorMedication management: “There were no separate TMARs for each administration and no protocol for the 'as required' cream to direct staff when to apply it.”
minorCare planning: “Others would benefit from more detail on how support should be provided should people fall or become unwell.”
minorCare planning: “there was not always sufficient information to support staff to respond in an emergency situation”
Strengths
· People and relatives felt safe with staff and trusted them
· Safe recruitment practices were followed
· Staff were well trained, supported and attended regular supervisions and spot checks
· Staff treated people with dignity, kindness and respect
· Person-centred care delivered by a small, regular team who knew people well
Quality-Statement breakdown (24)
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: Supporting people to live healthier lives, access healthcare services and supportNot 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
caring: Respecting and promoting people's 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: Supporting people to develop and maintain relationships to avoid social isolationNot 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: Working in partnership with othersNot rated