Person Centred Services Limited received an overall Good rating on its first CQC inspection, with four of five key questions rated Good and a person-centred, open culture praised by people, relatives and staff. Well-led was rated Requires Improvement due to insufficiently robust governance systems, including audit records lacking individual names and governance failing to identify gaps in health-condition-specific risk assessments and timely care plan updates.
Concerns (5)
moderateCare planning: “changes were not always promptly reflected in people's care plans. Staff were updated on any changes through the electronic system, but a delay may risk staff not being unaware of the changes”
moderateGovernance: “records were not robust because people's names were not recorded in the audits. This meant patterns and trends for a specific person may not be swiftly identified.”
moderateGovernance: “Governance systems had not identified risk assessments were not always in place for health conditions to provide staff with an understanding of the health condition”
moderateRecord keeping: “Quality assurance checks had not always ensured people's care plans were consistently and promptly updated as their needs changed.”
minorStaff training: “Some staff needed specialised training to be able to support all people using the service. The registered manager was aware of this, and was already sourcing training for Parkinson's disease, epilepsy”
Strengths
· People and relatives consistently reported feeling safe and well-cared for by consistent, familiar staff.
· Medications were administered safely by trained staff with regular competency checks and audits.
· Staff promoted people's independence and treated them with dignity and respect.
· Complaints and concerns were responded to and dealt with swiftly by the registered manager.
· The registered manager demonstrated a person-centred, open and positive culture, described by staff as committed and approachable.
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the law; Supporting people to eat and drink enoughNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversity; Respecting and promoting people's privacy, dignity and independenceNot 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: 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: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated