Phemacare Ltd, a small domiciliary care agency in Birmingham supporting 4 people, was rated Requires Improvement overall following a focused inspection of Safe and Well-Led domains, with breaches of Regulation 19 (fit and proper persons) and Regulation 17 (good governance) identified. Key failures included unsafe recruitment practices, inadequate medication records, insufficiently detailed care plans, and ineffective audit systems, representing a continued failure to improve since the previous 2020 inspection.
Concerns (7)
criticalGovernance: “Systems in place to assess, monitor and improve the quality and safety of the services provided were not always effective. This was a continued breach of regulation 17 (Good Governance)”
criticalRecord keeping: “The employment application form for 1 member of staff had not been fully completed and there was no record of their employment history.”
moderateMedication management: “One person needed staff to apply a prescribed cream. This information had not been recorded... Care plans did not include required information about what medicines people were taking and why.”
moderateCare planning: “Care plans and risk assessments did not give clear and detailed instruction to staff on how to provide safe care and support.”
moderateMissed or late visits: “Over the last 12 months the provider had received 12 complaints about call times... some calls were shorter than the agreed length of time.”
moderateSafeguarding: “2 staff we spoke with were not clear on the action to take if they needed to raise concerns externally.”
minorIncident learning: “There were no records of any accidents or incidents, therefore we were not able to check records to see what action had been taken in response.”
Strengths
· Staff had completed safeguarding training and felt able to raise concerns
· Staff adhered to infection control procedures and all 4 checked staff had received infection control training
· People confirmed staff wore correct PPE during calls
· Staff knew people well and people said they were happy with the care provided
· Provider took immediate action to update care plans and re-check right to work information following inspection
Quality-Statement breakdown (10)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Learning lessons when things go wrongRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement