We Care Together Southampton received an overall Good rating across all five key questions at its first inspection as a newly registered domiciliary care provider serving 39 people. Minor shortfalls were identified in risk assessment detail, MCA documentation, and failure to notify CQC of two safeguarding concerns, but no regulatory breaches were found and the service demonstrated strong person-centred practice and governance.
Concerns (7)
moderate
Safeguarding
: “The registered managers had not notified us of 2 safeguarding concerns that had occurred within the service as they were not aware this was required.”
moderateGovernance: “The provider notified CQC about some events that happened in the service however had not notified us of 2 safeguarding concerns.”
minorCare planning: “Environmental risk assessments could have been more detailed in order to fully inform staff about a range of potential risks associated with pets and moving and handling equipment.”
minorCare planning: “Where people were at risk of self-harm, risk assessments could have been more detailed about how this risk was to be managed and mitigated.”
minorRecord keeping: “Records did not initially reflect this however the registered manager had documents such as emails to evidence repeatedly requesting references.”
minorConsent / capacity: “Whilst the provider was working within the principles of the MCA, they had not routinely been completing MCA assessments, or making best interest decisions for people.”
minorCare planning: “Care plans were not formally audited as the registered manager knew they were current as they were reviewed so frequently, between weekly and 3-monthly.”
Strengths
· Staff safely recruited with all pre-employment checks completed including DBS checks prior to commencing in post.
· Electronic medicines administration records provided a live view to managers enabling prompt follow-up of missed medicines.
· Strong links with district nursing teams and tissue viability specialists supporting effective wound care management.
· Person-centred care plans developed from assessments covering all aspects of health and well-being.
· Provider limited new referrals to maintain capacity, ensuring sufficient staff time for person-centred care.
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
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 to provide consistent, effective, timely careGood
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: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
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: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Continuous learning and improving care; Engaging and involving people using the serviceGood