Person Centred Care Company achieved significant improvements since its previous requires improvement rating, with safe and effective now rated Good; however, governance remains in breach of Regulation 17 due to ineffective quality assurance audits and insufficient provider oversight, keeping the overall rating at Requires Improvement.
Concerns (5)
criticalGovernance — “The provider had failed to fully establish effective systems and processes to demonstrate the quality and safety of the services provided was effectively managed.”
moderateMedication management
— “medicines audits lacked any detail, with no reference to current legislation and good practice guidance.”
moderateStaff training — “we found staff training records were incomplete. The registered manager told us they were considering purchasing an online package to proactively track and chase staff training.”
moderateLeadership — “The provider had not kept full oversight of the service. This could have identified the issues with the quality assurance systems we found at this inspection.”
minorConsent / capacity — “There were no training records to show staff were up to date with MCA training. However, staff were aware of the need to give people choices.”
Strengths
· Safe recruitment procedures confirmed staff were of suitable character, with DBS checks, references and proof of identity in place.
· Sufficient staffing levels with people confirming there were always enough staff attending to provide care needed.
· Staff assigned consistently to the same people, with enough travel time between calls.
· People received medicines as prescribed; staff competency in medicines administration regularly checked.
· Staff received induction including Care Certificate, mandatory training and shadowing experienced colleagues.
Quality-Statement breakdown (13)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; Supporting people to live healthier lives and access healthcare servicesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; Duty of candourGood