Twilight Recruitment Ltd, supporting one person at the time of inspection, was no longer in breach of regulations 12 and 17 following improvements to recruitment, policies and risk awareness. However, the service remained Requires Improvement overall as care plans, risk management detail, formal quality checks and recorded reviews still needed further development.
Concerns (6)
moderate
Care planning
: “Whilst the plan of care gave information about tasks to be completed, this was basic... in the event of new staff, more detailed information was required”
moderateCare planning: “Improvement was needed to increase the detail in the person's risk management plan so staff could refer to this if needed”
moderateGovernance: “Some quality checks took place on records, but these were not always recorded and were limited. Further improvement was needed.”
moderateRecord keeping: “reviews were not recorded in the plan of care. The provider recognised the need to formally record the verbal reviews that took place.”
minorConsent / capacity: “improvement was needed to include this in the plan of care so information was available to be referred to if needed”
minorCommunication with families: “the feedback and dates of discussions were not recorded. We discussed the importance of formal feedback systems with the provider”
Strengths
· Person received consistent care from one staff member who knew them very well
· Person and relatives gave positive feedback describing staff as kind and caring
· No missed or late care calls and no complaints received
· Recruitment policy and pre-employment checks improved since last inspection
· Staff completed training including medicines, infection prevention and PPE use
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Staffing and recruitmentNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Staff work with other agencies to provide consistent, effective, timely careNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and controlNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationshipsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving care; Working in partnership with othersNot rated