Depax Care, a small Sheffield domiciliary care agency supporting five people, was rated Good overall at its first inspection in April–May 2022, with safe, effective, caring and responsive all Good. Well-led was rated Requires Improvement due to underdeveloped quality assurance systems, gaps in complaints recording and a need for more comprehensive staff competency assessments before the service expanded.
Concerns (6)
moderate
Governance
: “the quality monitoring systems needed to be further developed to ensure they had clear systems to safely manage and monitor the service before it expanded.”
moderateComplaints handling: “one person said they had made a complaint, and there was no record of it.”
moderateStaff competency: “a comprehensive assessment of staff skills including medicines management and manual handling competencies was needed to assure the registered manager that staff practices were current and safe.”
minorCultural competency: “one member of staff was talking about their religious beliefs in front of them. This was not respectful or engaging practice.”
minorStaff training: “You have to show the staff the basics even things like putting the oven on.”
minorRecord keeping: “any complaints, lessons learned, and actions taken would be recorded to help improve the service.”
Strengths
· People felt safe with staff; relatives agreed family members were safe.
· Safe recruitment processes with all required pre-employment checks completed.
· Medicines were managed safely and staff had been trained in medicine management.
· Effective infection prevention and control systems with good PPE stocks.
· Care plans contained detailed information on preferences, choices and communication needs.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
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 and access healthcare servicesGood
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: Supporting people to develop and maintain relationships to avoid social isolationGood
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 requirements; Continuous learning and improving careRequires 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