This service is a domiciliary care agency. It provides personal care to people living in their own homes. At the time of our assessment, 52 people were receiving support with personal care. The service provides support for both younger and older adults. Date of assessment: 3 April 2025. This assessment was carried out due to the length of time since the previous assessment in November 2019. When incidents or complaints occurred, the provider carried out an investigation and actions were identified to reduce possible risks. Medicines were administered as prescribed and following best practice. The provider had a recruitment process which enabled them to identify the skills of new applicants. Care workers completed a range of training and received support from senior management through team meetings and supervisions meetings. The provider assessed people’s care needs to ensure these could be met by the care workers. Staff felt supported by the senior management. Up to date policies and procedures were in place. The provider had a quality assurance process to monitor the quality of aspects of the service.
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Life Care Plus Limited was rated Requires Improvement overall at its first CQC inspection, with two regulatory breaches identified: failure to obtain satisfactory references before employing staff (Regulation 19) and failure of governance systems to detect recruitment and medicines administration record shortfalls (Regulation 17). The service performed well in the effective, caring and responsive domains, with person-centred care plans, good training, and positive feedback from relatives.
Concerns (5)
criticalStaffing levels: “the provider requested, but had not always waited until they received, satisfactory references before employing staff. One staff records contained no employment or any other references”
criticalGovernance: “The provider's quality assurance systems had not identified these shortfalls so these could be rectified appropriately.”
moderateMedication management: “there was an individual medicine (to help people sleep)...recorded as administered by staff at, 'Breakfast' between 1 to 17 August...not in line with the recorded prescribed dosage”
moderateRecord keeping: “errors in the completion of the medicine administration records (MARs) had not been identified and investigated by the provider”
minorConsent / capacity: “a third file contained the person's written consent for their relative to make decisions for them when it stated...the person did not have the capacity to make their own decisions. This was not in line with the MCA.”
Strengths
· Sufficient staff employed with no missed calls and punctual attendance reported by relatives
· Person-centred care plans detailing communication preferences, diversity needs and individual wishes
· Staff received comprehensive training including safeguarding, MCA, infection control, dementia care and medicines administration
· Registered manager introduced staff to people and families prior to service commencement
· Strong safeguarding awareness among staff with clear reporting processes
Life Care Plus Limited is rated Good overall following a November 2019 inspection, having improved Safe from Requires Improvement, though Well-Led remains Requires Improvement due to governance systems not yet fully embedded and a recruitment risk assessment gap not identified by the provider's own audit processes. People and relatives were consistently positive about caring, competent staff, person-centred care planning, and an approachable registered manager.
Concerns (4)
moderateGovernance: “not all systems were embedded. The registered manager was still in the process of developing some of the audit tools. While there were suitable templates in place to record if staff recruitment processes had been completed, they were not yet used.”
moderateGovernance: “a risk assessment was not written to reflect the safety measures taken when a reference could not be obtained. The provider's quality assurance system had not identified this shortfall.”
minorRecord keeping: “one person's documents were not consistent in stating when a medicine should be taken before or after food. This was because one support plan stated after a meal rather than before a meal.”
minorStaffing levels: “one relative told us that whilst usually the staff called as scheduled they had experienced an occasional lapse in service. 'On one occasion one staff didn't turn up and once one was an hour late.'”
Strengths
· People and relatives spoke positively about care workers, describing them as experienced, friendly and caring.
· The registered manager assessed people's needs prior to offering a service and developed person-centred care plans.
· Staff received comprehensive induction and training including safeguarding, MCA, medicines administration, dementia and end of life.
· An electronic login/out system was introduced to monitor care call attendance, eliminating missed calls since implementation.
· Medicines administration records were completed appropriately and audited regularly with errors addressed promptly.
Quality-Statement breakdown (23)
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
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
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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: Supporting people to develop and maintain relationships to avoid social isolationGood
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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
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
well-led: Continuous learning and improving care; Working in partnership with othersGood