Updated 31 July 2024
The assessment of the service started with an onsite visit on 7 August and was completed when final feedback was given on 9 October. The assessment covered safe, responsive and well led. Staff received training and felt supported in their roles. The registered manager and Nominated Individual were proactive in developing the service to meet the needs of people including developing productive working relationships with commissioners, providers and health care professionals and by networking and learning from managerial consultants and sector organisations. However, we found a breach of good governance. The governance systems were not effective in identifying and addressing such things as informal concerns and feedback, management of care calls by trained staff and inconsistency of care records. We have asked the provider for an action plan in response to the concerns found at this assessment. This assessment has been carried out using an updated CQC process whereby moderation has been used. This involves assessment teams reviewing sufficient evidence to review a complete Quality Statement (i.e. all applicable evidence categories) and recording this in our system using a single evidence category. We have used our scoring moderation process to ensure the correct quality statement score is given and have provided a full report for our findings for each quality statement. This will be available for providers in the draft report under a single evidence category. When we publish this it will be displayed under the quality statement only.