Caremark Three Rivers was rated Good overall at its first inspection, with people receiving safe, effective, caring and responsive personalised care from a well-trained staff team. Well-led was rated Requires Improvement solely because the service did not have its own registered manager, triggering a regulatory limiter on the rating.
Concerns (4)
moderate
Leadership
: “As they were not registered for Caremark Three Rivers, this meant the service did not have a registered manager as is required.”
moderateGovernance: “As a result of not having a registered manager we have applied a limiter. This means the service cannot be rated above requires improvement in the well-led section”
minorMissed or late visits: “Some people had experienced occasions where their care visits were late, however they confirmed they were notified in these circumstances”
minorStaffing levels: “some felt that travel time between visits was not always sufficient. One member of staff told us, 'The allocated call times are well managed, the traveling time is five minutes but certain areas it should be between seven and ten minutes.'”
Strengths
· Safeguarding systems in place and staff trained to report concerns
· Medicines managed safely with staff competency checks
· Effective infection prevention and control procedures including PPE use
· Robust recruitment processes including DBS checks
· Personalised care plans reflecting people's preferences and wishes
Quality-Statement breakdown (19)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
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; access healthcare; working with other agenciesGood
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: 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
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 empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Continuous learning and improving careRequires improvement
well-led: Working in partnership with othersRequires improvement