Date of Assessment: 25 February to 7 March 2025. This service is a care at home agency providing support to adults of all ages. CQC only inspects where people are receiving the regulated activity of personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. At the time of this assessment, 4 people were receiving personal care support. At the last inspection the provider was in breach of the legal regulations in relation to their recruitment and governance systems. Improvements were not found at this assessment, and the provider remained in breach of these regulations. The provider had not completed appropriate recruitment checks to ensure staff were safely employed. The provider’s governance processes did not identify or address areas of concern. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. At the last inspection, the provider was also in breach of the legal regulation in relation to their management of medicines. Improvements were found at this assessment and the provider was no longer in breach of this regulation. However, further improvements were needed to ensure medicines records were accurate and detailed. Risks to people’s safety were not always assessed and documented to ensure they were managed safely. The provider did not always promote a culture of continuous learning and improvement. Assessments of people’s needs lacked detail and people’s care plans were not adequately personalised. People’s capacity to give consent was not always recorded. People were treated with kindness and compassion. There were enough staff available to support people. Staff monitored people’s health and wellbeing. The provider promoted people’s equality in access to care and provided them with information in formats they could understand.
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Ros and Mos House Support Ltd received an overall rating of Requires Improvement at its first inspection, with regulatory breaches identified in medicines management (Reg. 12), governance (Reg. 17), and staff recruitment (Reg. 19). Despite these shortfalls, the service demonstrated genuine strengths in caring, responsiveness, and staff training, with consistently positive feedback from people and relatives.
Concerns (9)
criticalMedication management: “Exact timings for when medication needed to be administered were not recorded on the MAR Chart. They had been recorded as 'morning' and 'evening'.”
criticalMedication management: “A person was given an additional dose of medication and this was not identified during the registered manager's audit.”
criticalGovernance: “Systems and processes to monitor, audit and improve the overall quality of the service were not robust enough. This was a breach of Regulation 17.”
criticalStaff competency: “Relevant recruitment checks were not always completed before staff started work. We saw gaps in recruitment files, such as incomplete application forms and no interview notes.”
criticalCare planning: “1 person who was at risk of choking did not have a choking risk assessment in place which meant staff would not know how to support the person.”
moderateRecord keeping: “A person was prescribed with a cream which needed to be applied regularly, however, this was not recorded on the MAR Chart.”
moderateGovernance: “Audits were ineffective and not reviewed regularly. The manager's audits had failed to identify the concerns we found with the management of medicines and staff recruitment files.”
moderateCare planning: “The care plans did not contain a picture of the person, their likes, dislikes or their medication details. No information was available about people's life history.”
minorEnd-of-life care: “There was limited information in the support plans we reviewed relating to people's end of life wishes.”
Strengths
· People felt safe and staff knew how to protect them from abuse; staff received safeguarding training and understood escalation responsibilities.
· Sufficient staffing levels maintained with no missed visits reported by relatives.
· Staff received thorough induction, mandatory training, and medication competency assessments.
· People and families were involved in care planning and described staff as kind, caring and respectful.
· Infection control practices were followed consistently, with PPE provided and used on all visits.
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires 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
well-led: Continuous learning and improving care; Working in partnership with othersGood