ComityHearts Care Services Ltd provides safe, caring and responsive domiciliary care with good outcomes for people, but was rated Requires Improvement overall due to a breach of Regulation 17 (good governance), with inadequate oversight of training, supervision and competency check records and no embedded service improvement plan at the time of inspection.
Concerns (6)
critical
Governance
: “Audits had been carried out but had not been translated into a service improvement plan.”
moderateRecord keeping: “Robust record keeping was not in place to support the delivery of care. Staff supervisions and competency checks were not consistently recorded.”
moderateSupervision / appraisal: “Staff told us there was regular supervision and competency checks, however, this was not always documented.”
moderateStaff training: “Staff were up to date with training and there was a training matrix in place. However, records was not kept up to date.”
minorMissed or late visits: “The provider did not record late visits, however, staff told us they had enough time on visits to allow them to complete all the necessary care.”
minorIncident learning: “The provider held meetings with staff to share lessons learnt. However, this was not always documented.”
Strengths
· Person receiving care was safe and protected from the risk of abuse and avoidable harm; safeguarding training was up to date.
· Care plans were personalised, reflecting life history, personal interests and individual needs.
· Staff were kind, caring and respected privacy, dignity and independence.
· Specific capacity assessments and best interest decisions were clearly documented in line with MCA.
· Consistent care team with safe recruitment practices including DBS checks, employment history and references.
Quality-Statement breakdown (16)
safe: Staffing and recruitment; Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
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
responsive: Planning personalised care to ensure people have choice and control; improving care quality in response to complaintsGood
responsive: Meeting people's communication needsGood
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: Working in partnership with others; duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood