First inspection of this domiciliary care agency rated Requires Improvement overall, with breaches of Regulation 17 (good governance) and Regulation 19 (fit and proper persons employed) due to inconsistent risk assessments, medicines records, and incomplete recruitment/DBS checks. Effective, caring and responsive domains were rated Good, with relatives praising kind, culturally competent staff and improved health outcomes.
Concerns (6)
critical
Governance
: “The providers oversight systems were not robust. The systems had not identified the recruitment policy was out of date and had not been followed when making recruitment decisions.”
criticalStaff competency: “We found some checks had not been carried out correctly with the Disclosure and Barring Service (DBS) when people were recruited.”
moderateMedication management: “Topical medicines were not consistently included on people's medication administration record, which meant people were at risk of not receiving prescribed medicines.”
moderateCare planning: “Risk assessments were not consistently documented. For example, skin integrity risk assessments and medicine administration.”
moderateRecord keeping: “Audits had not identified where initial assessments were not documented, risk assessments and care plans were not documented.”
moderateLeadership: “The registered manager did not have an effective oversight of the service. The quality assurance processes had failed to identify the issues we found at the inspection.”
Strengths
· Staff trained to recognise and report safeguarding concerns
· Sufficient staffing levels with punctual visits reported by relatives
· Strong cultural competency including Punjabi-speaking staff to support communication
· Kind, caring staff who treated people with dignity and respect
· People and relatives involved in developing and reviewing care plans
Quality-Statement breakdown (23)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk from abuseGood
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, 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
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: Planning personalised careGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
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: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving care; Working in partnership with othersGood