NCC First Support - Northern, a reablement domiciliary care service in Norfolk, was rated overall Good at its first inspection in August 2022, with four of five key questions rated Good. The Well-led domain required improvement due to insufficiently robust governance, including care record audits only conducted after people left the service and quality assurance processes failing to drive timely remedial action.
Concerns (7)
moderate
Governance
: “Audits of care records were only undertaken when people had stopped using the service. This meant there was no oversight to ensure care records contained enough detail and all risks had been identified.”
moderateCare planning: “Risks relating to people's individual care needs were not always planned for. A review of care plan audits showed senior staff identified needs which had not been risk assessed.”
moderateRecord keeping: “Audits of people's medicines and care plans did not detail what remedial action had been taken and by when where shortfalls were found.”
minorMedication management: “Our review of people's Medicines Administration Record (MAR) charts showed these did not always contain sufficient detail, for example the time of day and the frequency of administration were not always detailed.”
minorStaff training: “A review of training data showed not all staff were up to date with the mandatory training set by the provider.”
minorStaffing levels: “Through our conversations with people, some felt the service was short-staffed. One relative told us, '…it does seem as though they are short of staff.'”
minorPerson-centred care: “People told us they were not always asked if they had a preference about the gender of the staff who would be supporting them.”
Strengths
· People consistently reported feeling safe with staff and praised their caring, respectful attitude.
· Staff demonstrated good understanding of people's individual needs and how to keep them safe.
· Effective partnership working with healthcare professionals, including timely referrals to district nurses, occupational therapy, and falls teams.
· People were supported to regain independence in line with the reablement model.
· Staff respected people's dignity, privacy, and promoted choice and control in daily care.
Quality-Statement breakdown (19)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
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; access healthcare services; working with other agenciesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirements; continuous learningRequires improvement
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