DCL-PRO Services Ltd improved from Requires Improvement to Good following a focused inspection of Safe and Well-led, having remediated prior breaches of Regulations 12 and 17. The service demonstrated robust risk management, safe recruitment, effective governance and a positive person-centred culture with 7 people receiving care at the time of inspection.
Strengths
· Risks assessed and mitigated across falls, choking, diet, nutrition, health conditions and moving and handling with up-to-date review processes.
· Robust staff recruitment including criminal records checks, employment history verification and induction.
· Effective incident and accident recording with lessons shared at staff meetings.
· Regular audits completed by registered manager with a service improvement plan tracking actions and timescales.
· Positive person-centred culture; people and relatives complimentary of staff; 24-hour on-call available.
Quality-Statement breakdown (12)
safe: Assessing risk, safety monitoring and management
Good
safe: Systems and processes to safeguard people from the risk of abuse and avoidable harmGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Continuous learning and improving careGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsGood
First inspection of this domiciliary care agency identified breaches of Regulation 12 (safe care and treatment) due to absent risk management plans for specific health conditions and Regulation 17 (good governance) due to unrecorded audit outcomes. Despite these issues, the service was rated Good for effective, caring and responsive with positive feedback on training, person-centred care and partnership working.
Concerns (4)
criticalCare planning: “There were no risk management plans to provide guidance to care workers on how the risks associated with these conditions affected people and to how to manage those risks”
criticalGovernance: “the provider did not have robust systems to assess, monitor and improve the quality and safety of the service. This was a breach of regulation 17 (Good Governance)”
moderateRecord keeping: “when these checks were carried out the information and any actions which had been identified to address areas for improvement were not recorded”
moderateIncident learning: “The registered manager could not provide records for the COVID 19 risk assessments.”
Strengths
· Robust recruitment process with employment history checks, criminal record checks and references
· Care workers completed mandatory training and felt well supported by management
· Adequate PPE supply and infection control training during COVID-19 pandemic
· Person-centred approach respecting religious, cultural and language preferences
· Care workers given flexibility to spend extra time to reduce social isolation
Quality-Statement breakdown (24)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: End of life care and supportNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
well-led: Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated