Focused inspection of safe and well-led at this small domiciliary care agency rated the service Good overall, with safe improving to Good and well-led remaining Requires improvement. Concerns centred on incomplete audits and lack of a system to learn from accidents and incidents, while medicines, safeguarding and timeliness of visits were positive.
Concerns (4)
moderateGovernance: “Audits carried out by the provider were not always completed. We found gaps in the audits we reviewed and there were no actions taken”
moderateIncident learning: “There was no system in place to improve the safety of the service following accidents or incidents.”
minor
Record keeping
: “frequent competency checks, however these were not documented”
minorCommunication with families: “There were no staff meetings or staff surveys”
Strengths
· Visits carried out on time with staff reporting they had enough time to support people
· Safeguarding concerns were raised and recorded; staff up to date with safeguarding training
· People received their medicines safely with regular medicine audits and electronic recording
· Person-centred risk assessments reflecting individual needs such as diabetes and catheter care
· Positive feedback about approachable leadership and supportive culture
Quality-Statement breakdown (9)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot 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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Continuous learning and improving careNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated