Allcare retained an overall Good rating with Safe rated Good, but Well-led remained Requires Improvement due to governance and audit systems that were not effective at identifying and driving improvement. Call timeliness, communication and partnership working had improved since the previous inspection, though quality assurance processes and feedback gathering still needed development.
Concerns (6)
moderateGovernance: “Review of the governance arrangements to assess and monitor the quality and safety of the service found these needed developing to ensure they were effective at identifying and driving improvement”
moderateGovernance: “The two most recent audits conducted by the registered manager dated July and August 2022 focused on recent staffing issues and action taken but did not include an effective review of other areas”
moderateRecord keeping: “Copies of people's MAR charts were provided, but there was no analysis of these records to ensure they were being competed correctly.”
moderateStaffing levels: “Recent staffing issues had impacted on people receiving their allotted calls.”
minorMissed or late visits: “confirmed the majority of people received their calls on time, with 29% of calls being 15-45 minutes late.”
minorCommunication with families: “people and relatives spoken with said they did not remember completing any feedback forms.”
Strengths
· People reported feeling safe and well cared for by regular, familiar staff
· Medicines were managed safely with training and routine spot checks
· Safe recruitment practices including DBS checks and references
· Good infection prevention and control practices with appropriate PPE use
· Open and transparent approach with duty of candour, including formal apologies
Quality-Statement breakdown (12)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood