L&F Care Services, a small domiciliary care agency in Bedford, achieved an overall Good rating on its first CQC inspection, with people and relatives consistently reporting safe, kind and personalised care. The only area of concern was Well-Led, rated Requires Improvement due to the registered manager's inconsistent understanding of regulations and care planning quality assurance systems, prompting a recommendation to refresh regulatory knowledge.
Concerns (2)
moderateGovernance: “The registered manager's inconsistent understanding of regulations and systems used in the service meant that the assessment of the quality of care delivered was not always as effective as it could be.”
moderateLeadership: “They were not always able to demonstrate a clear understanding of the regulations and how they impacted on their role...this had resulted in some delays to access some records requested by the CQC.”
Strengths
· People and relatives reported feeling safe and described staff as kind, caring and respectful.
· Medicines were safely managed with electronic recording ensuring correct administration and remote oversight.
· Staff received full training including Care Certificate induction, shadowing, and regular competency observations.
· Person-centred care planning with monthly reviews, surveys and flexible visit scheduling to meet changing needs.
· Strong multi-agency working with health and social care professionals, praised by external professionals.
Quality-Statement breakdown (25)
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: 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: Supporting people to develop and maintain relationships to avoid social isolationGood
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, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood