All Day Care Services Ltd received an overall Good rating across all five key questions in its first CQC inspection, with inspectors finding people were safe, well-supported by consistent staff, and treated with dignity and respect. Minor shortfalls were identified in medicine audit effectiveness, mental capacity assessment documentation, and varied staff knowledge of the MCA, though none were found to have impacted on people's care.
Concerns (5)
moderate
Medication management
: “Medicine audits did not always demonstrate issues or discrepancies had been identified. For example, one medicine administration record showed some medicines had not always been administered.”
moderateConsent / capacity: “For one person their capacity to consent to the service being provided to them had not been assessed and a best interests decision made.”
minorStaff competency: “Staff had varied understanding in these areas, with some staff being very knowledgeable and others having much less confidence in those areas.”
minorRecord keeping: “We found some discrepancies with some people's records and where information needed to be more clearly recorded.”
minorCare planning: “Written reviews did not evidence involvement of people and their relatives. We found further information could be provided around people's life histories and interests.”
Strengths
· People were supported by regular and consistent staff who knew them well, fostering positive relationships.
· Staff were proactive in monitoring people's health conditions and escalating concerns to health professionals appropriately.
· The registered manager demonstrated good understanding of adult safeguarding and was closely involved in oversight of care quality.
· Care was flexible and responsive to people's changing needs, with effective communication ensuring staff were kept informed.
· Staff were safely recruited with appropriate checks carried out prior to employment.
Quality-Statement breakdown (21)
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
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 care; Supporting people to live healthier livesGood
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
responsive: End of life care and supportGood
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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood