First inspection of this small Derby-based domiciliary care agency rated Requires Improvement overall, with shortfalls in recruitment records, risk assessments, care plan currency and governance audits. Effective, caring and responsive domains were rated Good, with positive feedback on consistent staff, partnership working and personalised care.
Concerns (8)
moderate
Record keeping
: “Records were not always accurate, complete or up to date.”
moderateCare planning: “Care plans were not always up to date and some risk assessments had not been completed.”
moderateGovernance: “Audits had not always been effective at identifying shortfalls and ensuring improvements were made.”
moderateStaff training: “Records were not always available to show care staff had been recruited in line with the provider's policy”
moderateLeadership: “the service management and leadership was inconsistent. Leaders and the culture they created did not assure the delivery of high-quality care.”
minorMedication management: “We found one person's skin creams were not recorded on their MAR and the registered manager took action to put this in place.”
minorComplaints handling: “they resolved any issues as they had occurred, however records had not been kept of these.”
minorConsent / capacity: “their mental capacity to understand and consent to their care was now different from that recorded in their original MCA assessment.”
Strengths
· Staff competence assessed and enough time to travel between visits
· People knew the consistent care staff providing their care
· Medicines managed safely with trained, competence-checked staff
· Effective safeguarding systems with appropriate referrals to local authority
· Strong partnership working with GPs, district nurses and occupational therapists
Quality-Statement breakdown (22)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Using medicines safelyNot rated
safe: Systems and process to safeguard people from the risk of abuse; learning lessons when things go wrongNot rated
safe: Preventing and controlling infectionNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Staff working with other agencies; supporting people to access healthcareNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot 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: Supporting people to develop and maintain relationships to avoid social isolationNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
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 requirementsNot rated
well-led: Duty of candour and continuous learning and improving careNot rated
well-led: Promoting a positive, person-centred, open and inclusive culture; engaging people and staffNot rated
well-led: Working in partnership with othersNot rated