Active Friendly Support Ltd improved from Requires Improvement to Good across Safe, Effective and Well-Led domains in this focused inspection, having fully remediated a previous Regulation 19 breach around pre-employment checks. Minor gaps remain in accident/near-miss recording and CQC notification awareness for open safeguarding incidents, but the service demonstrates a strong person-centred culture with positive feedback from professionals, staff and people using the service.
Concerns (3)
moderateGovernance: “the registered manager was unaware of the updates required for incidents where an open safeguarding is in place. The registered manager agreed to provide future notifications for these incidents.”
minor
Incident learning
: “although incidents were recorded, there was low recording of accidents and near misses. The provider agreed to send a reminder to staff to ensure all accidents and near misses were always documented.”
minorRecord keeping: “Further work around information management in some areas was required to ensure effective management oversight.”
Strengths
· Strong person-centred culture with people involved in planning their own support and decisions
· Safe recruitment processes including DBS checks; previous breach of Regulation 19 fully remediated
· Staff knowledgeable about safeguarding and individual needs, wishes and goals of people supported
· Effective partnership working with health and social care professionals, praised as 'outstanding, caring, client led service'
· Staff received specialist training including epilepsy, diabetes, autism and learning disability; STOMP principles implemented
Quality-Statement breakdown (15)
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Using medicines safelyGood
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: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting people to live healthier lives and access healthcareGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Duty of candour; continuous learning and improving careGood
well-led: Managers and staff being clear about roles, quality performance, risks and regulatory requirementsGood