Date of assessment: 9 October 2024 to 17 October 2024. This service provides personal care to people in their own homes as well in other settings including community facilities and supporting people on residential breaks. The service provides support to both children and adults. This assessment was carried out in response to concerns we received about the quality and safety of the care provided to people. We found 2 breaches of the legal regulations in relation to consent and governance. We found improvements were needed to ensure people were consistently supported safely and that their rights were protected. The provider did not have effective systems and processes in place to monitor the quality of care people received, and they had not always identified areas to improve. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The overall rating for this service is requires improvement based on the findings of this inspection. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website.
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First inspection of this domiciliary care agency rated Requires Improvement overall, with breaches of regulations 11 (consent), 13 (safeguarding) and 17 (good governance), plus regulation 18 notification failures. Caring and responsive domains were rated Good, with person-centred care delivered by a knowledgeable, well-recruited staff team.
Concerns (7)
criticalSafeguarding: “when incidents of potential abuse had occurred, they had not always been appropriately reported to the safeguarding team, as required”
criticalConsent / capacity: “When people lacked capacity to make decisions for themselves capacity assessments and best interests decision were not in place.”
criticalGovernance: “The quality monitoring systems in place are not always effective in identifying concerns and driving improvement within the home.”
moderateStaff training: “The registered manager and staff did not demonstrate an understanding in this area and staff had not received training.”
moderateRecord keeping: “The system the provider had in place to record people's care was not always secure. Records were shared from staffs' personal phones to the providers data base.”
moderateIncident learning: “when incidents and accidents occurred the information was recorded on a log sheet. There was no evidence that this information was used to make changes.”
moderateLeadership: “The provider had failed to update us when they had moved from their registered office location to another address.”
Strengths
· Person-centred care plans individual to people's needs
· Safely recruited staff who knew people well
· Sufficient staffing levels to support people
· Staff protected and respected people's privacy and dignity
· Positive, empowering culture from management and staff team
Quality-Statement breakdown (24)
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
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: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
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 and supporting people to access healthcareGood
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: Supporting people to develop and maintain relationships and follow interestsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
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: Engaging and involving people using the service, the public and staffGood