Reign Supreme Care Services Ltd, a small domiciliary care agency in Leicester, was rated Good overall following a focused inspection of Safe and Well-Led, improving from Requires Improvement at its previous inspection in 2019. The service demonstrated robust governance, consistent care delivery, and safe practices, with only minor gaps identified in mental capacity assessment detail and as-required medicines protocols, both addressed during the inspection.
Concerns (2)
minorConsent / capacity: “some assessments did require more detail. The registered manager reviewed these assessments during the inspection to show fully how people's capacity had been determined.”
minorMedication management: “Some additional information was needed to record why and what effect the medicine had. The registered manager amended the protocols during the inspection.”
Strengths
· Registered manager had full oversight with monthly audits, quality assurance, and safe staff recruitment practices.
· Care calls consistently provided at arranged times with proactive communication when timings were expected to change.
· Medicines managed safely with trained staff, competency checks, MARs completion, and monthly medicines audits.
· Robust infection prevention and control procedures with adequate PPE always available to staff.
· Person-centred care with regular care plan reviews involving people and relatives.
safe:Insufficient evidence to rateeffective:Insufficient evidence to ratecaring:Insufficient evidence to rateresponsive:Insufficient evidence to ratewell-led:Insufficient evidence to rate
Reign Supreme Care Services Ltd was inspected on 19 October 2018 but could not be rated as only one person was receiving personal care, providing insufficient evidence to assess service quality. Key gaps included incomplete risk assessments, limited care plan personalisation, a staff safeguarding knowledge gap, and incomplete quality audits, though the registered manager addressed several issues promptly after the inspection.
Concerns (6)
moderateCare planning: “Care plans were not fully personalised as it did not include important information about the person's likes and dislikes and personal history.”
moderateSafeguarding: “A staff member was not aware of how to report to other relevant outside agencies if necessary, if they had not been acted on by the management of the service.”
moderateRecord keeping: “The care plan did not always contain risk assessments to reduce or eliminate the risk of issues affecting people's safety.”
moderateGovernance: “There were no audits undertaken on important quality issues such staff training.”
minorStaff training: “Staff had not received training in a number of people's specific long-term health conditions such as stroke and end-of-life care.”
minorComplaints handling: “The provider's complaints procedure...did not contain contact details about the complaints authority or details of the local government ombudsman.”
Strengths
· Staff recruitment checks including DBS were in place to protect people from unsuitable staff.
· Relative reported staff were kind, friendly, caring and respected dignity and cultural needs.
· Staff demonstrated understanding of Mental Capacity Act and sought consent before providing care.
· Service worked in partnership with other agencies and followed professional guidance.
· Registered manager was responsive to inspection findings and provided remedial evidence post-visit.
Quality-Statement breakdown (8)
safe: Safeguarding systems were not comprehensively in place to keep people safe.Insufficient evidence to rate
safe: Risk assessments were not comprehensively in place to protect people from risks to their health and welfare.Insufficient evidence to rate
effective: Staff had largely received training though training on some relevant issues had not yet been provided.Insufficient evidence to rate
effective: Staff demonstrated awareness of MCA and obtained consent before providing care.Insufficient evidence to rate
caring: Staff were caring, respected dignity, privacy, independence and cultural needs of people.Insufficient evidence to rate
responsive: Care plans lacked personalised information about the person's history, likes, dislikes and aspirations.Insufficient evidence to rate
responsive: Complaints procedure was incomplete, missing contact details for the complaints authority and ombudsman.
Reign Supreme Care Services Limited was found to require improvement primarily due to unsafe staff recruitment practices, constituting a breach of Regulation 19, and gaps in staff induction training. Caring and responsive practice were rated Good, with people and families involved in care planning and staff demonstrating person-centred values.
Concerns (5)
criticalStaffing levels: “Staff recruitment records for the two members of staff were incomplete. They did not include all the pre-employment checks and information required.”
criticalGovernance: “One member of staff did not have an enhanced Disclosure and Barring Service (DBS) check within their records.”
moderateStaff training: “The topics listed did not include safeguarding people from abuse or safe moving and handling practices of people when delivering care and support.”
moderateLeadership: “The registered manager was not able to speak with confidence about the training staff undertook as part of their induction.”
moderateStaff competency: “This meant the registered manager could not be confident that staff could effectively meet people's needs.”
Strengths
· People were supported by a consistent member of staff, including the registered manager, promoting caring relationships.
· Care plans were developed with involvement of people or their family members and were person-centred.
· Risk assessments were carried out and measures were in place to support people safely.
· Staff understood safeguarding responsibilities and knew how to raise concerns.
· Registered manager proactively liaised with health professionals and organised occupational therapy assessments.
Reign Supreme Care Services Ltd requires improvement overall, with gaps in risk assessment documentation, staff recruitment records, capacity assessments, and governance audits presenting safety and leadership concerns. Caring, responsive and effective practice was rated Good, with relatives reporting kind, personalised and culturally sensitive support.
Concerns (6)
moderateCare planning: “Checks to people's safety were not always recorded in their care notes. For example, a risk assessment stated a person's catheter needed to be checked on each call. This had not always been recorded.”
moderateRecord keeping: “People did not have individual personal evacuation plans for the quickest and safest way to leave their homes in the event of fire.”
moderateStaff competency: “The employment history for two staff was not included in their records. The registered manager said this had not been carried out as these staff were agency staff.”
moderateConsent / capacity: “Mental capacity assessments had not been completed to determine people's capacity to independently make important decisions.”
moderateGovernance: “Audits to monitor the service and drive improvement were not in place for issues such as the robustness of staff recruitment and people's risk assessments, and whether calls had been timely.”
minorComplaints handling: “The procedure did not include all relevant information such as how to contact the complaints authority and the local government ombudsman.”
Strengths
· Relatives confirmed staff were caring, kind and friendly, and took time to communicate with people they supported.
· Care plans were personalised with information about people's likes, dislikes and personal history.
· Staff had received safeguarding training and understood their responsibilities to protect people from abuse.
· Staff supported people's cultural backgrounds, including food from their cultural backgrounds.
· People's privacy, dignity and independence were respected, with staff knocking and seeking permission before entering rooms.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
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
Insufficient evidence to rate
well-led: Quality assurance audits were incomplete, with no audits on important issues such as staff training.Insufficient evidence to rate
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
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: Improving care quality in response to complaints or concernsGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: End of life care and supportGood
well-led: Continuous learning and improving careRequires improvement
well-led: Planning and promoting person-centred, high-quality care and support; duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staff; working in partnership with othersGood