Date of assessment: 12 June 17 June 2025. We visited the service on 12 June 2025. This is a domiciliary care service, registered to provide personal care for people living in their own homes in the community. They provide support to people with a range of different needs including older people and those with a physical disability. At the time of the assessment the service was providing the regulated activity of personal care for 29 people. We rated this service under our previous methodology in May 2022 where it was inspected and rated as requires improvement overall. At this assessment we rated the provider good. At the last assessment the provider was found to be in breach of the legal regulation relating to good governance. Improvements were found at this assessment, and the provider was no longer in breach of the regulation related to good governance. The provider had introduced an Electronic Medication Administration Record (EMAR) system and a digital care record system, to ensure good governance. People were not receiving formal reviews at the time of the assessment. We spoke with the management who told us they had been completing informal reviews however would complete formal reviews straight away. No-one we spoke with said they had any concerns relating to their care plans. Staff treated people as individuals offering choice and supporting independence.
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First inspection of this domiciliary care agency found a breach of Regulation 17 (Good governance) due to ineffective quality assurance, limited audits, and inconsistent documentation of supervision, training renewals, complaints and medicine competency checks. People received kind, person-centred care from a consistent team with positive feedback about management, but governance systems required strengthening.
Concerns (9)
criticalGovernance: “The provider had failed to ensure the quality assurance processes in place were effective. We found limited evidence of effective audits and there was no service improvement plan in place.”
criticalMedication management: “Medicine audits were not robust enough to demonstrate good governance. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
moderateRecord keeping: “We found the provider was not consistently documenting all actions taken. There were gaps in care documentation, a lack of recording supervision inconsistent auditing and a lack of oversight of renewing training.”
moderateStaff training: “Some training such as safeguarding and infection control was not renewed therefore we were not assured staff knowledge remained current.”
moderateSupervision / appraisal: “The provider could not evidence effective support was in place for staff. Although staff told us there was regular supervision, this was not always documented.”
moderateCare planning: “People's care plans identified general support needs; however, we found specific information missing. For example, records lacked details on how to hoist someone and what sling to use.”
moderateComplaints handling: “There was limited oversight of complaints. There was a complaints log which lacked details and actions taken following complaints were not always documented.”
minorStaff competency: “The provider ensured all staff who administered medicines were trained to do so and had frequent competency checks. However, these were not always documented.”
minorIncident learning: “The provider had systems in place to identify lessons to be learnt. The provider held monthly meetings with staff to share lessons learnt. However, this was not always documented.”
Strengths
· Safe recruitment processes including DBS and references from previous employers
· Care delivered by a consistent team with no reports of missed or late visits
· Sufficient staffing levels with enough time to complete care
· Positive feedback from people and relatives about kind and caring staff
· Approachable and responsive management team
Quality-Statement breakdown (18)
safe: Using medicines safelyNot rated
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
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 live healthier lives, access healthcare services and supportNot 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: Improving care quality in response to complaints or concernsNot 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 needs; End of life care and supportNot 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: Working in partnership with others; How the provider understands and acts on the duty of candourNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated