Melburay Ltd, a small domiciliary care agency supporting four children, was rated Good overall on its first CQC inspection, with strengths in safeguarding, recruitment, staff training and a caring culture. The Responsive domain was rated Requires Improvement due to insufficiently detailed and non-person-centred care plans, failure to produce accessible information formats, and gaps in complaints policy awareness among people using the service.
Concerns (7)
moderateCare planning: “some care plans did not contain sufficient detail regarding people's routines, and preferences related to personal care support”
moderateRecord keeping: “staff were using the same electronic care log for different family members who were both receiving care from this provider”
moderatePerson-centred care: “Records of care were not always person-centred.”
moderateMedication management: “The care plan did not contain enough detail about when to administer this medicine... their competency had not been assessed in line with best practice guidance.”
moderateStaff competency: “Staff received training in the administration of medicines, however, their competency had not been assessed in line with best practice guidance.”
minorCommunication with families: “Feedback surveys showed that some people were not familiar with the complaints policy and did not know who to contact to make a complaint.”
minorComplaints handling: “Not all people understood how to make a complaint. We have made a recommendation about ensuring people understand the complaints policy.”
Strengths
· Staff demonstrated good understanding of safeguarding and whistleblowing procedures
· Safe recruitment processes followed including DBS checks and right-to-work verification
· Electronic Call Monitoring system in place to monitor timekeeping and alert missed visits
· Comprehensive induction including Care Certificate completion for new staff
· Regular supervision provided every three months with records confirmed
Quality-Statement breakdown (24)
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
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills, and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity, and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
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 requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Continuous learning and improving careGood