First inspection of a small domiciliary care agency identified a breach of Regulation 17 (good governance) due to lack of quality monitoring, incomplete risk assessments, and shortfalls in staff training and competency checks. While caring and responsive domains were rated Good with positive feedback about staff, the service was rated Requires Improvement overall due to systemic governance and oversight weaknesses.
Concerns (10)
criticalGovernance: “Systems had not been established to effectively assess, monitor and mitigate risks to the health, safety and welfare of people using the service.”
criticalGovernance: “We have identified a breach in relation to the governance and leadership of the service, this is about a lack of systems and quality monitoring checks completed by the registered manager and provider.”
moderateIncident learning: “There were no systems in place to respond to a person if they had a potential injury such as a bruise. This could be a potential sign of abuse or indicator a person needed some more support.”
moderateSafeguarding: “some staff did not know they could report concerns to the local authority and to us. This is important to promote people's safety.”
moderateCare planning: “People did not always have complete risk assessments, which identified and explored all the risks which they faced. Staff did not have clear and thorough care plans to guide them about how certain risks should be managed.”
moderateStaff training: “There was no timely follow up training or recorded checks by the registered manager to see if staff had understood this training. When we asked staff to tell us about this training, staff were unable to recall what they had learnt”
moderateStaff competency: “Thorough competency checks were not being completed and recorded to check this training had been effective and people were safe.”
moderateConsent / capacity: “When an individual was considered to not always have capacity, this was identified by the registered manager. But they had not documented how they had reached this conclusion and what actions should be taken”
moderateRecord keeping: “Their care plan, risk assessment, and reviews did not explain this risk, what advice professionals had given, and how this need was to be managed by staff.”
moderateLeadership: “The registered manager and provider were not always clear about their role in terms of quality monitoring and knowing the regulatory requirements.”
Strengths
· People felt safe and spoke positively about kind, respectful staff
· Care visits were at times people wanted with staff they were happy with
· Registered manager was approachable and supportive of staff, providing regular supervisions and team meetings
· Medication administration records were complete with no gaps
· Person-centred care delivery with focus on mental and emotional well-being
Quality-Statement breakdown (21)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Staffing and recruitmentNot rated
safe: Learning lessons when things go wrongNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Assessing people's needs and choices; delivering care in line with standardsNot 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
caring: Respecting and promoting people's privacy, dignity and independenceNot 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: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
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: Engaging and involving people using the service, the public and staffNot rated