31-32, Southernhay East

“Date of assessment: 25 September to 18 October 2024. 31/32 Southernhay East is a domiciliary care agency providing personal care services to mainly older people in their own homes. There were 89 people receiving personal care. At this assessment we spent time with 2 people using the service and spoke with 13 people and 5 relatives on the telephone. We received feedback from 12 staff members and 5 external health professionals working with the service, to help us assess and understand how people’s care needs were being met. At this assessment, we rated this service as Good. People’s needs were assessed, they received care, support and treatment which reflected their needs. People felt they were being treated with kindness, empathy and compassion. Health and care needs of people were understood by staff and leaders. However, we identified a breach in the regulation relating to good governance. The service did not have an effective governance system to monitor and improve the quality of care and safety of the service. Although some training had been completed, there were gaps in staff learning and training oversight with a lack of staff competency checks. Leaders did not hold staff meetings and regular staff supervision to ensure staff were supported and able to discuss any issues. Policies did not include missed visits or self-neglect processes and complaints were not recorded or analysed in detail to prevent recurrence. There was no on call system to ensure staff were supported fairly when shifts required covering. Risks to people's care were well managed and appropriate actions taken however, staff did not always update documentation within care plans to ensure all required information was present and shared. Care plans were detailed about peoples’ needs and reviewed but there was no oversight of reviews. The service had enough staff to meet people’s needs however, the rotas did not take into account training, meetings and supervisions.”