Mrs Nina Glarvey is a domiciliary care agency rated Good overall, with Safe rated Good but Well-led requiring improvement due to ineffective governance, incomplete audits, and inadequate monitoring of staff training and supervision. No evidence was found that people were at risk of harm, and people's direct experience of care was largely positive.
Concerns (5)
moderateGovernance: “The quality assurance processes in place were not always effective. Audits in relation to recruitment records were incomplete and did not pick up on the shortfalls we found.”
moderateSupervision / appraisal: “The registered manager did not have effective systems to monitor staff training and supervision. Training, supervision records & training development plans were not up to date.”
moderate
Staff training
: “Training records and training development plans were not up to date. Supervisions were not taking place regularly in line with the company policy.”
minorRecord keeping: “Staff meetings were not recorded, and we could not be assured there were taking place on a regular basis.”
minorOther: “Recruitment checks were in place but not always robustly documented or complete. We found no evidence during this inspection that people were at risk of harm from this concern.”
Strengths
· People and relatives felt staff kept them safe, with one relative stating their mother is kept 'exceptionally safe'.
· Medicines were safely managed; people received medicines in a timely manner with monitoring systems in place.
· Infection prevention and control systems were in place, including up-to-date COVID-19 guidance and PPE access.
· Risks were assessed with appropriate measures in place, and risk information was communicated effectively.
· People had person-centred care plans in place which considered their preferences.
All Seasons Home Care achieved a Good rating across all five key questions at its first inspection under this location, with people and relatives consistently praising the caring, reliable and person-centred service. The main area for improvement was incomplete risk documentation within care records, which the registered provider addressed immediately during the inspection visit.
Concerns (3)
moderateRecord keeping: “we were informed one person was at risk of choking. We observed a note within the care file to state that foods were to be cut up, but this had not been updated within the care record.”
minorGovernance: “They told us they audited work on a daily basis. They did not however document this to show it took place.”
minorCommunication with families: “Two people said they weren't always consulted with when their rota's changed. One person said, 'They don't always tell me when my rota changes.'”
Strengths
· People spoke positively about staff being caring, kind, reliable and always carrying out commissioned hours
· Strong safeguarding knowledge among staff with clear reporting procedures understood
· Suitable medicines management systems including MAR sheets audited monthly
· Robust recruitment procedures including DBS checks and two references prior to employment
· Active training programme including dementia friends initiative and specialist health professional input