Breakthru Care Ltd, a small domiciliary care agency in Walsall serving 17 people, received a Good rating across all five key questions at its first CQC inspection in June 2023. Minor issues were identified around generic risk assessments, an ineffective call-monitoring system due to Wi-Fi limitations, gaps in end-of-life care training, and a MAR recording gap, all of which the registered manager acted on promptly during the inspection.
Concerns (4)
moderate
Record keeping
: “1 person had not had a regular medication recorded on their MAR sheet due to an ordering dispute.”
minorCare planning: “Risk assessments were not always completed in a person centred way. For example, some risk assessments were generic and not tailored to each individual.”
minorGovernance: “The provider had a system in place to monitor that people received the correct call times. However, this was found to not always be effective due to variable Wi-Fi in people's homes.”
minorStaff training: “The provider did not have specific end of life care training in place for staff.”
Strengths
· People felt safe and staff demonstrated clear understanding of care plans and risk assessments.
· Medicines were managed safely with regular oversight, auditing, and staff competency observations.
· Staff received comprehensive induction, ongoing training including dementia and catheter care, and regular supervision.
· Person-centred care plans were active documents updated to reflect changing needs, with people involved in reviews.
· Consistent carers were allocated and people reported high satisfaction with staff compassion and responsiveness.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuse; learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
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
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 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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; continuous learning and improving careGood
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 staff, working in partnership with othersGood
well-led: How the provider understands and acts on the duty of candourGood