XL Care Services Limited, a small domiciliary care provider in Leeds, rated Good overall at its first inspection, with staff delivering safe, caring and personalised support to 6 people. Well-led was rated Requires Improvement due to gaps in regulatory notification knowledge, absence of systematic lessons-learnt processes, and a recommendation to strengthen safeguarding training.
Concerns (7)
critical
Governance
: “They did not fully understand information sharing requirements when concerns had been identified and when notifications should be sent to the CQC and the local authority.”
moderateSafeguarding: “Some staff did not know about how to contact the local authority safeguarding team if they had concerns.”
moderateIncident learning: “We did not see routine analysis to identify any patterns or trends to reduce any potential future risks and help improve the service.”
moderateGovernance: “There was little evidence to show how lessons learnt were routinely used to improve the quality of the service.”
minorMedication management: “Protocols for administering as needed medicines were not always in place and MAR charts did not contain body maps for topical medication.”
minorRecord keeping: “People told us initial assessments had taken place and they were involved in the development of their care plans. However, initial assessments had not been recorded.”
minorConsent / capacity: “Staff understood the importance of seeking consent before providing care or support. However, some staff did not fully understand the requirements of the MCA.”
Strengths
· People felt safe and staff were described as kind, caring and consistent in attending scheduled visits.
· Safe recruitment practices including DBS checks were in place.
· Medicines were supported safely with regular MAR audits and staff competency checks.
· Staff completed induction and ongoing training including the Care Certificate for new care staff.
· People's privacy, dignity and independence were consistently promoted.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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
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: Meeting people's communication needsGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood