Diversicare Limited received a Good rating across all five key questions at its first inspection in January 2024, with people and relatives reporting highly positive experiences of care. Recommendations were made regarding medicines protocols, staff recruitment record-keeping, and governance audit robustness, all of which the provider began addressing during the inspection process.
Concerns (3)
moderate
Medication management
: “protocols relating to 'as required' medicines were not clear as they did not always guide staff on how to administer variable dose medicines.”
moderateGovernance: “Management audits were not always robust enough and more audits could be included to ensure better provider oversight.”
minorRecord keeping: “Some staff had gaps in employment which had not been addressed and a full employment history had not been sought.”
Strengths
· Enough skilled and experienced staff employed; relatives praised staff time keeping and consistency of the care team.
· Detailed, person-centred risk assessments and care plans guided staff effectively on individual care needs.
· Strong safeguarding awareness among staff; people reported feeling safe using the service.
· Registered manager worked well with healthcare professionals including district nurses to achieve good health outcomes.
· Positive, open culture with strong staff morale; people and relatives spoke highly of both staff and management.
Quality-Statement breakdown (20)
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candour; Working in partnership with othersNot rated