First inspection of newly registered domiciliary care agency rated Good overall, with Safe rated Requires Improvement due to gaps in risk information, recruitment records, incident trend analysis, and mixed feedback on staffing consistency. Effective, Caring, Responsive and Well-led were rated Good, with strong governance, person-centred culture and collaborative working with health professionals.
Concerns (10)
moderate
Care planning
: “Information about some risks was not consistently up to date or clear.”
moderateRecord keeping: “In the case of two workers, a full employment history had not been recorded.”
moderateIncident learning: “The systems in place to regularly and systematically review all incidents and accidents to check for safety related themes and trends needed to be developed further”
moderateStaffing levels: “We received mixed feedback about the reliability and consistency of the service.”
moderateStaff competency: “Some people did not feel fully confident or secure with their care worker and further action was being taken to mentor staff where necessary.”
moderateConsent / capacity: “Three of the care plans we viewed did not include signed consent from the person or their legally appointed representative.”
minorMedication management: “information relating to the use of 'As required' or PRN medicines needed to be more comprehensive”
minorSupervision / appraisal: “Supervision records did not include a focus on the ongoing personal development and learning of staff.”
minorEnd-of-life care: “information about the person's wider priorities for their future care had not been incorporated into an end of life or advanced care plan.”
minorPerson-centred care: “Some of the language used in a small number of these records was not fully person centred.”
Strengths
· Staff knew how to recognise the signs of abuse and worked well with other agencies to protect people from financial and physical abuse.
· People were receiving their medicines as prescribed and MARs were regularly audited.
· Staff undertook a suitable induction, Care Certificate training and competency assessments.
· Staff worked collaboratively with healthcare professionals to meet people's health needs effectively.
· People and relatives described staff as kind, caring and respectful, with positive relationships.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff working with other agencies to provide consistent, effective, timely careNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot 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: 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, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated