During an assessment under our new approach
We assessed a total of 94 evidence categories from the safe, effective, caring, responsive and well-led key questions. Our overall rating for this service is requires improvement. We found both good practice and areas of concern. We found 2 breaches of the legal regulation in relation to safe management of medicines and non-reporting of safeguarding events to CQC.
The provider had systems in place to record events and report safeguarding incidents to the local authority. However, we found that not all safeguarding incidents had been reported to the CQC as required.
Improvements were needed in the management and record-keeping of medicines to ensure people received them safely. While people’s care was assessed before services began, care reviews were not always conducted consistently or recorded in line with the provider’s policy. Despite these findings, most people felt safe during care calls and described staff as respectful and attentive in their care. Care plans were personalised to reflect individuals’ identities and preferences.
Governance systems required strengthening, as they had not identified several issues highlighted during our assessment. At the time of the assessment, there was no registered manager in post, although the current manager had submitted an application to register with the CQC, which was under review. The manager demonstrated a clear plan and vision for developing the service, including improving engagement with staff and people and embedding changes through an action plan developed in collaboration with the local authority.