Date of inspection: 23 January 2025 to 07 February 2025. Jaysh Care Services is a domiciliary care agency and provides personal care to people living in their own homes. CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. At the time of this inspection 4 people were receiving support with personal care. We inspected to check if improvements had been made following our last inspection. The provider was previously in breach of the legal regulations in relation to safe care and treatment, need for consent, staffing and good governance. Improvements were found at this inspection and the provider was no longer in breach of these regulations. Staff assessed and mitigated risks and care plans guided safe practice. People were supported to have choice and control and were involved in planning their care. Medicines were managed safely. Governance systems had improved and the provider was keen to learn and to continue to improve the service. Staff knew people well and received appropriate training and support. There were enough staff to meet people's needs. Staff were kind and caring and had a good understanding of how to meet people’s needs. There was a system in place to allow people to express any concerns or complaints they may have. Information in some risk assessments needed to be more comprehensive so staff would always be clear on what action was required to ensure risks would be managed.
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Jaysh Care Services received an overall rating of Requires Improvement across all five key questions at its October 2022 inspection, with regulatory breaches identified in risk management (Reg 12), medicines management (Reg 12), consent/MCA (Reg 11), staffing and training (Reg 18), and governance (Reg 17). The service has been rated Requires Improvement or Inadequate for three consecutive inspections, with persistent failures in care planning, medication administration records, staff competency oversight, and governance systems that failed to drive sustainable improvement.
Concerns (11)
criticalMedication management: “one person had 51 gaps on their MAR in September 2022 for two topical creams and two topical spray medicines. Another person had 76 gaps in their MAR with no explanation”
criticalCare planning: “Care plans did not contain enough information about people's specific medical conditions... no guidance for staff to follow should these people have an incident”
criticalConsent / capacity: “Some people had specific mental capacity assessments in place however, there were no best interest decisions recorded when a person was assessed as lacking capacity”
criticalGovernance: “Several audits were carried out, but these were not done in line with their policy because they were not completed effectively and did not drive improvement.”
criticalStaff training: “Eight staff members who had been in post for over 4 months had not completed the Care Certificate... 1 staff member had completed a list of 33 different training subjects in 1 day”
moderateSupervision / appraisal: “Staff did not receive supervision in line with the provider's policy... 'Staff have a supervision in the first month and then a supervision at 6 months in post'”
moderatePerson-centred care: “People were not always receiving person-centred care and support. People's care records sometimes lacked detail and did not fully capture their individual needs and wishes.”
moderateCommunication with families: “They don't inform us if they are going to be late... If you ring the manager, they don't answer the phone. You have to chase the manager about things”
moderateRecord keeping: “spelling mistakes, surname and address not correct... Access to care records shows lack of detail, so you do not get a comprehensive view of what has occurred during each visit”
moderateIncident learning: “When things went wrong, lessons were not always learnt to support improvement... improvements had not been sustained and the provider was found to be in breach of regulations.”
moderateStaff competency: “The registered manager told us staff received observations and competency assessments... however; they were unable to provide any evidence this took place.”
Strengths
· Safeguarding incidents had been reported to the local authority and a safeguarding policy was in place and up to date
· Staff had access to PPE and used it effectively; people confirmed masks and gloves were worn as required
· Staff demonstrated knowledge of dignified and respectful care, including privacy during personal care
· People's dietary needs were recorded and people reported being well supported with food and drink choices
· The provider had a complaints policy and complaints were responded to appropriately
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongRequires improvement
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: End of life care and supportRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candourGood