Walfinch Greater Manchester South received an overall Good rating on its first inspection, with strengths in safeguarding, medicines management, person-centred care, and positive staff and family feedback. The Well-led domain was rated Requires Improvement due to governance audits failing to identify issues around recruitment checks, MCA assessments, supervision frequency, and outdated policies.
Concerns (7)
moderate
Governance
: “The audits in place had not identified the issues we found.”
moderateConsent / capacity: “The service had not ensured when there was doubt over a person's capacity, the necessary assessments had been undertaken.”
moderateStaffing levels: “Systems and processes were not always robust when the service recruited staff. The service had not completed all necessary recruitment checks before some staff's employment had started.”
minorRecord keeping: “The service had moved address and the provider had failed to complete the correct paperwork to notify CQC of this change.”
minorSupervision / appraisal: “Staff supervisions and appraisals were taking place, but not in line with policy.”
minorStaff competency: “Staff had completed MCA training, however, they lacked some knowledge in this area.”
minorCare planning: “The service did have a pre-assessment form in place, but one had not been completed for the care package we reviewed.”
Strengths
· Safeguarding policies and procedures were in place and being followed with appropriate risk assessments.
· Medicines were safely managed with MAR records in place and regularly audited.
· Good stocks of PPE and up-to-date IPC practices and training.
· Person-centred care plans in place, regularly reviewed and accessible via an app.
· Family members spoke positively about staff and management; one described staff as 'exceptional'.
Quality-Statement breakdown (16)
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
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 standardsGood
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
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
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needs; improving care quality in response to complaintsGood
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; duty of candour; continuous learning and improving careGood
well-led: Engaging and involving people using the service, the public and staffGood