ComCare received an overall Good rating across the two inspected key questions (Safe and Well-led), with inspectors finding people were protected from harm, supported kindly and in line with Right Support, Right Care, Right Culture principles. Shortfalls in pre-employment recruitment checks and previous staffing inconsistencies were identified but had been addressed by the new management team by the end of the inspection.
Concerns (4)
moderateStaffing levels: “previous to the inspection, numbers of staff had not always been enough to meet the needs of people using the service”
moderateRecord keeping: “Recruitment files had not been robustly audited, and we identified shortfalls in pre employment checks being completed before staff were working alone.”
moderate
Governance
: “improvements needed to identify where previous employment checks had not been completed. For example, where references had not been returned in a timely manner prior to initiating independent working”
moderateLeadership: “The manager described the previous culture amongst staff as poor.”
Strengths
· Staff were polite, kind and respectful; people reported feeling safe and well supported with personal care.
· Medicines were managed safely with electronic administration records checked daily and clear protocols for 'as and when' medicines.
· Detailed, person-centred risk assessments and positive behaviour support plans were in place.
· The service met the principles of Right Support, Right Care, Right Culture for people with a learning disability and autistic people.
· Strong incident learning culture: staff debriefed after incidents, escalated learning, and the provider worked with the local authority safeguarding lead.
Quality-Statement breakdown (11)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
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: 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 care; Working in partnership with othersGood