First inspection of this newly registered domiciliary care agency rated Requires Improvement overall and across all five key questions, with breaches of Regulations 9 and 12 due to inadequate care planning, generic risk assessments and late calls. Quality assurance, governance and recruitment checks were not robust, although staff were trained, kind and consistent according to relatives.
Concerns (10)
critical
Care planning
: “Information within people's care plans was limited and did not provide adequate guidance or direction to support person centred care.”
criticalPerson-centred care: “there was not enough information about people's personalised care needs in care plans. This was a breach of regulation 9 (Person Centred Care)”
criticalMissed or late visits: “People experienced inconsistent timings of their care visit. People were not consistently informed when staff were going to be late.”
criticalOther: “Risks of people had been assessed however these were generic and in places contained names of other people using the service.”
moderateStaff training: “in three staff files reviewed, application forms had not been completed in full and the provider had not explored gaps in employment history.”
moderateGovernance: “Whilst the provider had quality assurance systems in place these had not been effectively used to identify where quality was compromised.”
moderateLeadership: “Relatives told us they struggled to communicate with the registered manager due to language barriers and felt that communication and response to telephone calls was poor.”
moderateComplaints handling: “One relative told us they had raised a concern relating to the lateness of calls, however, did not feel the registered manager had listened to them or made changes.”
moderateRecord keeping: “Daily notes did not consistently contain the start and end time of each visit.”
moderateCommunication with families: “There was a lack of evidence of engagement between the registered manager and people.”
Strengths
· Relatives told us the staff team were caring, kind and consistent which made people feel safe.
· Staff had completed an induction process including the Care Certificate and were confident in their role.
· Infection control policy in place, updated to reflect government guidance, with staff trained and adequate PPE supplies.
· Staff had received safeguarding training and were knowledgeable of recording and reporting concerns internally and to external organisations.
· Registered manager completed spot checks and competence checks of staff skill and knowledge.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Using medicines safelyNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot 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 diversity; Respecting and promoting people's privacy, dignity and independenceRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
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 requirements; Promoting a positive cultureRequires improvement
well-led: How the provider understands and acts on the duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated