Shadz Care received a Good rating across all five key questions at its first CQC inspection in November 2021, demonstrating strong person-centred care, effective multi-agency working, and a positive open culture. Two minor governance concerns were noted around delayed safeguarding notifications to the local authority and a delay in notifying CQC of incidents, both of which the registered manager acknowledged and addressed.
Concerns (2)
moderate
Safeguarding
: “the registered manager had not reported all incidents to the local safeguarding team. Although actions had been taken including referral to a person's GP and review of medicines, this lack of reporting meant the risk to people might not be managed as safely as it could have been.”
minorIncident learning: “although prompt action taken ensured people remained safe, there was a delay in notifying us. The provider now understood not to wait until the matter was completely resolved.”
Strengths
· Staff demonstrated strong knowledge of safeguarding and risk management, with robust risk assessments regularly reviewed and updated.
· Trained and competent staff administered medicines safely, promoting independence where possible.
· Comprehensive staff recruitment process with thorough checks and person-centred involvement of service users in staff selection.
· Effective infection prevention and control practices, including full COVID-19 testing programme participation.
· Open learning culture with transparent incident reporting and lessons shared across the staff team.
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: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting 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 preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
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: Continuous learning and improving careGood