31-32, Southernhay East

During this assessment, we looked at all 8 quality statements in the key question of safe. We rated the safe key question as good. Recruitment checks were completed. The service had provided training and people and staff said they could conduct their role. However, there was a lack of oversight to ensure staff had all received appropriate training and competency checks (see well led). Risks to people’s care were well managed with clear information, however this was not recorded consistently (see well led key question). Staff arrived on time and stayed for the required duration of the care calls. People and relatives said they could confidently raise safety concerns, and these were listened to and acted on by the registered manager. Staff followed nationally recognised best practice to ensure infection risks to people were minimised.

We assessed all of the quality statements within this key question. Our rating for the effective key question is good. We received positive feedback regarding staff, and people said staff respected their choices and asked for consent. Staff worked well together to meet the needs of people. Most people told us they were involved in assessing their needs and were able to state their choices and preferences as to how their care and support was provided. People and their relatives had confidence in the knowledge and skills of staff. People’s care and support was planned and delivered in line with current best practice and legislation. The registered manager and staff team wanted to continually improve the service to provide high-quality care. The service was working in line with the principles of the Mental Capacity Act 2005 (MCA) and care plans contained clear information about people’s cognitive needs. However, not all staff had completed effective training in MCA as there was no oversight by leaders of training completed. There was no evidence that this had impacted people receiving support.

We assessed all of the quality statements within this key question. Our rating for the caring key question is good. People told us staff were kind, caring and respected people’s right to privacy and to be treated with dignity. People were encouraged to do as much as they could for themselves, to maintain, build and further strengthen their independence to undertake the tasks of daily living. Staff listened to and understood people’s needs, views and wishes. Staff responded to people’s needs during times of distress. Staff wellbeing was promoted to support them to always deliver person-centred care.

We assessed all of the quality statements within this key question. Our rating for the responsive key question is good. People received care and support that was tailored to them and their individual needs. People were encouraged to speak up and raise concerns if they had them. People felt they were involved in planning their care. There was partnership working to make sure that care and treatment met the diverse needs of the people using the service.

We assessed all of the quality statements within the well led key question. Our rating for this question is requires improvement. Whilst people and relatives we spoke with said they were happy with their care, the provider and registered manager did not have effective governance and management systems to have clear oversight of the service and ensure it was running smoothly, especially as the service grew. We did not find people receiving a service had any negative outcomes, but we found a breach of the legal regulation relating to good governance. The provider and registered manager were responsive to our findings and keen to make improvements. The provider had already started to take action to address these concerns, including reviewing their policies and procedures, staff training and support, and reviewing care plans. Most staff were provided with fair and equal opportunity at work and were valued and respected. Most staff were positive about the management team and felt confident that any concerns raised would be addressed. However, policies and procedures did not formally support staff and enable them to share any issues or meet face to face regularly as a team. Oversight and governance of staff training, staff supervision and appraisals, spot checks, complaints, accidents and incidents, care plan reviews, survey results and the on-call system were lacking. Management of missed visits, environmental risk assessments and self-neglect were also lacking. The registered manager was aware of their statutory responsibilities in relation to informing CQC of certain changes, such as applying to relocate the registered office.