Solihull Care Limited was rated Requires Improvement overall at its first inspection, with a breach of Regulation 17 (Good Governance) due to ineffective quality monitoring systems, absence of provider-level audits, poor incident learning, and inadequate staff training oversight. Caring was rated Good, reflecting consistent, compassionate staff relationships with people, though systemic leadership and governance failings across safe, effective, responsive and well-led domains posed risks to people's safety and wellbeing.
Concerns (12)
criticalGovernance: “The provider did not complete any audits or checks to ensure people received their care in line with the aims and values of the service.”
moderateIncident learning: “Lessons had not been learnt when things had gone wrong...incidents were not analysed to identify any patterns or trends.”
moderateMissed or late visits: “Between 1 and 30 September 2018 one person had received 120 care calls but only four of the 120 calls had been logged correctly by staff.”
moderateCare planning: “Some care plans lacked detail to help staff to provide person centred care...one person's care plan stated, 'prepare breakfast and feed [person].'”
moderateStaff training: “Staff members told us they had not been sufficiently supported to complete training. One staff member told us, 'I haven't done any training for quite a while.'”
moderateStaff competency: “Checks to ensure staff put their training into practice and checks to make sure they were competent to carry out their roles...were not completed.”
moderateMedication management: “People's completed medication administration records were returned to the office each month but documented audits to check people had received their medicines safely did not take place.”
moderateRecord keeping: “Accurate and up to date records of when staff had completed their training were not maintained. The general manager said, 'We need a proper matrix for that and we don't have one.'”
moderateConsent / capacity: “A mental capacity assessment had not been completed to determine what decisions the person could make for themselves.”
minorComplaints handling: “A relative explained they had been dissatisfied with how the provider had handled...a complaint raised in February 2018. They said, 'We never even got an apology.'”
minorSupervision / appraisal: “Since starting work at the service in July 2017 the registered manager told us they had not had opportunities to discuss their performance...with the provider.”
minorCommunication with families: “Some staff felt communication between them and their managers needed to improve because their requests for support were not always responded to promptly.”
Strengths
· People felt safe with consistent staff they knew and trusted, with staff demonstrating kind and caring attitudes.
· Staff respected people's dignity, privacy and independence, and understood the importance of promoting equality and human rights.
· Procedures were in place to safeguard people and staff understood their responsibilities to protect people from abuse.
· People received their medicines when they needed them, with positive feedback on medicine administration.
· Staff followed good infection control practices including use of gloves and aprons.
Quality-Statement breakdown (24)
safe: Call monitoring and visit loggingRequires improvement
safe: Risk assessmentsRequires improvement
safe: Recruitment proceduresRequires improvement
safe: SafeguardingGood
safe: Medicines administrationGood
safe: Infection controlGood
effective: Staff training and developmentRequires improvement
Solihull Care Limited improved from Requires Improvement to Good overall, with safe, effective, caring and responsive domains all rated Good following remediation of previous breaches. Well-led remains Requires Improvement due to the provider's continued lack of independent oversight and auditing, with over-reliance on the registered manager to assure quality and safety.
Concerns (3)
moderateGovernance: “The provider continued to be heavily reliant on the registered manager to assess the quality and safety of the service. The provider did not undertake any audits or checks.”
minorGovernance: “At the time of our visit, the rating for the service was not available on the provider's website as required. The display of the rating is a legal requirement.”
minorCare planning: “Two care plans we reviewed lacked minor detail to ensure care was provided consistently. The registered manager took immediate action to address this.”
Strengths
· Risk management had improved since the last inspection with clear risk management plans in place.
· Staff were recruited safely and sufficient staffing levels ensured consistent care calls at agreed times.
· People received their medicines as prescribed; medicine checks were implemented to identify and address errors promptly.
· Staff completed induction including the Care Certificate and ongoing training including epilepsy and dementia awareness.
· People received personalised care from a consistent staff team who knew them well.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
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: Ensuring consent to care and treatment in line with law and guidanceGood
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
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: Continuous learning and improving care; duty of candourRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Planning and promoting person-centred, high-quality care and supportGood
well-led: Engaging and involving people using the service, the public and staff; working in partnership with othersGood