Serenity Healthcare Services, a small domiciliary care agency supporting one person at the time of inspection, was rated Good overall with positive feedback on safety, training, and person-centred care. Well-led was rated Requires Improvement due to poorly written daily care records and the absence of an embedded auditing process.
Concerns (3)
moderate
Record keeping
: “some records only said, 'Got [person] up' or 'put [person] to bed', with no further information about how the care had been provided.”
moderateGovernance: “The registered manager had not implemented a system for auditing documentation. Consequently, poor record keeping in the daily notes had not been identified.”
moderateRecord keeping: “Daily notes, where staff recorded what care had been provided during visits were poorly written, as they did not provide enough detail, and some were illegible.”
Strengths
· Staff trained in safeguarding adults and children and knew how to keep people safe
· Safe recruitment processes including DBS checks
· Staff followed safe infection control practices and had good stocks of PPE
· Person-centred care plans developed with involvement of the person and their relative
· Regular supervision meetings and staff induction in place
Quality-Statement breakdown (19)
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Using medicines safelyInsufficient evidence to rate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies; Supporting people to access healthcare servicesNot 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 diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot 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
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: How the provider understands and acts on the duty of candourNot rated