Brendoncare Knightwood Mews, a domiciliary care agency supporting 6 people, was rated Good across all five key questions at its January 2023 inspection. Minor gaps in recruitment record-keeping and quality assurance documentation were identified, with recommendations made, but no regulatory breaches were found.
Concerns (3)
moderate
Governance
: “Quality assurance systems in place to monitor and improve the standard of the service were not always robust. Outcomes and actions were not always clearly recorded.”
moderateStaffing levels: “There was a recruitment process in place. However, we found this had not always been followed. Gaps in employment were not always explained and the medical fitness of staff had not always been reviewed.”
minorRecord keeping: “People were partners in their care services...these conversations were not always documented, we raised this with the manager and deputy manager, they took immediate action.”
Strengths
· People felt safe and expressed high satisfaction with care and staff: 'I felt safe from probably the first night', 'It's lovely.'
· Robust medicines management with trained, competency-assessed staff and safe ordering, storage and disposal procedures.
· Strong infection prevention and control procedures with adequate PPE supplies.
· Detailed, person-centred risk assessments reviewed monthly or on change of condition, with open incident-learning culture.
· Staff felt well-supported, valued and proud to work at the service, with positive team morale.
Quality-Statement breakdown (20)
safe: Staffing and recruitmentGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Planning personalised care to ensure people have choice and control; End of life care and supportGood
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, understanding quality performance, risks and regulatory requirements; Continuous learningGood
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 staff; Working in partnership with othersGood
Brendoncare Knightwood Mews received a Good rating across all five key questions at its May 2015 inspection, with inspectors finding a safe, well-staffed service where people felt cared for and involved in their support. Quality assurance systems were robust, staff training was responsive and effective, and there were no identified breaches of regulation.
Strengths
· People felt safe and reported a consistently good standard of care; safeguarding training was mandatory and staff could identify and report abuse.
· Robust recruitment procedures including DBS checks and references; sufficient staffing levels with flexible arrangements for additional care when needed.
· Medicines were managed safely with signed MAR records and secure storage for prescribed medicines.
· Staff received induction, shadow shifts, supervisions, appraisals, regular meetings, and observed practice; training was responsive to individual needs including specialist topics like motor neurone disease and dementia.
· Consent was always sought and staff demonstrated good understanding of the Mental Capacity Act 2005.
Quality-Statement breakdown (12)
safe: People were protected from abuse and avoidable harm; risks assessed and managedGood
safe: Safe recruitment procedures and sufficient staffing numbersGood
safe: Medicines managed consistently and safelyGood
effective: Staff had effective support and training to meet people's needsGood
effective: Consent sought in line with legislation; Mental Capacity Act applied appropriatelyGood
effective: Effective liaison with health care professionals when necessaryGood
caring: Staff showed concern for wellbeing and respected privacy and dignityGood
caring: People involved in planning their care and supported to exercise choice
Brendoncare Knightwood Mews was rated Good across all five key questions at its June 2017 inspection, continuing its Good rating from 2015. The service demonstrated consistently safe, person-centred care delivered by a stable, well-trained staff team, with only a minor finding regarding some out-of-date information held in office-based care records.
Concerns (1)
minorRecord keeping: “Some people's records held in the office contained some out of date information.”
Strengths
· Established, stable staff team with low turnover who know people well
· Robust safeguarding training and confident staff awareness of reporting procedures
· Safe recruitment procedures including DBS checks and written references
· Medicines safely managed with signed MAR records, body maps, and allergy documentation
· Staff received regular supervision, appraisals, and a thorough induction aligned to the Care Certificate
Good
responsive: Care and support reflected people's individual needs and preferencesGood
responsive: No complaints recorded since last inspection; minor concerns resolved informallyGood
well-led: Clear vision and values understood and followed by staffGood
well-led: Thorough quality assurance processes including monthly audits and clinical governance oversightGood