Community Care Experts received an overall Good rating across all five key questions at its first CQC inspection in November 2022, with inspectors finding people were safe, well supported and treated with dignity. Minor concerns were noted around the consistency of staff supervisions and governance oversight during an ongoing transition from paper to electronic records, resulting in a recommendation on records management.
Concerns (4)
moderate
Supervision / appraisal
: “staff did not receive frequent one-to-one sessions with the senior staff member...circumstances outside of their control had meant supervisions for all staff had not taken place.”
moderateGovernance: “The registered manager did not always have sufficient oversight and governance to effectively monitor the service. This was primarily due to the transition from paper based to electronic records.”
minorRecord keeping: “MAR audits could have been clearer in their completion...the provider was migrating fully to their electronic system.”
minorCare planning: “Risk assessments clarified potential risks...however this also included generic information around general risk occurrence. This meant that information in relation to specific risks was sometimes lost.”
Strengths
· People received their medicines when they needed them and medicines risks assessments were in place.
· Comprehensive pre-employment checks including DBS, references and photographic identification were carried out for all staff.
· Staff had plentiful supplies of PPE and understood how to prevent and control the spread of infection.
· People's privacy and dignity were well respected and staff knew people well, striving to deliver personalised care.
· Care plans clearly defined personal care duties and reflected people's preferences and communication needs.
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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 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: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Working in partnership with others; Continuous learning and improving careGood