Candlelight Homecare Services Wimborne Area Office is a domiciliary care service providing a regulated activity of personal care. The service was providing care and support to people in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection there were 73 people receiving personal care from the service. The assessment took place between 5 August and 8 August 2024. Since our last inspection improvements had been made at the service, these had been embedded and sustained. People had risk assessments in place for all their care and support needs. Medicines were managed safely, and an electronic system ensured changes were made when needed and medicines were administered on time. Lessons were learned and safeguarding procedures were followed. However, further improvements were implemented to ensure governance systems operated robustly within the service. The provider and registered manager were working towards further development and strengthening of the governance systems.
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Candlelight Homecare Services Wimborne Area Office was rated Requires Improvement overall following a March 2023 inspection, with a breach of Regulation 17 identified due to ineffective governance systems failing to monitor safety, medicines management, and risk. Staffing, safeguarding, infection control, and culture were positive, with people reporting high satisfaction and staff expressing pride in their work.
Concerns (5)
criticalGovernance: “Quality assurance systems were either not in place or did not operate effectively. Audits and planned monitoring were not in place and therefore had not identified the shortfalls found within the inspection.”
moderateMedication management: “Medicines assessments and instructions were not always detailed and in place for staff to follow. Guidance had not been created to ensure medicines taken 'as required' were offered consistently.”
moderateCare planning: “Instructions on safe ways of working to reduce or eliminate risks were not always documented. The information did not always inform care planning and was not always personalised.”
moderateRecord keeping: “Completed medicine administration records (MAR) were not visible to staff who were responsible for daily oversight of care visits.”
minorIncident learning: “Learning from incidents was not always shared within the service and providers locations.”
Strengths
· Robust infection prevention and control procedures with adequate PPE supplies confirmed by people and relatives.
· Sufficient staffing levels with continuity of care as an ongoing focus and dedicated visit co-ordinator.
· Strong recruitment processes including DBS checks, references, induction, shadow shifts, and competency assessments.
· Positive staff culture with high morale; staff felt valued, supported, and proud to work for the service.
· Approachable and supportive registered manager and management team praised by people, relatives, and staff.
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
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