Universal Complex Care improved from Requires Improvement to Good overall, having resolved previous breaches of Regulations 12, 17 and 19 relating to medicines management, governance and recruitment. All five key questions were rated Good, with people, relatives and professionals consistently positive about staff competence, leadership and personalised care delivery.
Strengths
· Medicines now managed safely following previous breach of Regulation 12; electronic system supplemented by paper records
· Safe recruitment practices restored following previous breach of Regulation 19, including DBS checks and person-led staff selection
· No missed care visits reported; staffing levels sufficient to meet people's complex needs
· Staff received thorough induction including shadowing, plus ongoing specialist training (e.g. PEG feeding)
· Positive leadership culture; registered manager praised by people, relatives, staff and external professionals
Quality-Statement breakdown (22)
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
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 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
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: 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: Working in partnership with others; Continuous learning and improving careGood