Excellence Healthcare

“CQC only inspects where people are receiving the regulated activity personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided. At the time of this inspection 4 people were receiving support with personal care.”

“Although the service was not supporting autistic people or people with a learning disability at the time of our assessment, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.”

“The assessment was prompted because of the length of time since our last inspection in 2018.”

“We found 3 breaches of regulation in relation to safe care and treatment, staffing, and good governance. We looked at all 5 key questions: Safe, Effective, Caring, Responsive and Well-led.”

“The provider had governance systems in place to monitor and improve the quality of the service, but these were not always effective. Care plans and risk assessments were in place to support people to manage risks. These needed some development, for risks to be managed effectively, and so staff had the guidance needed to support people safely. Recruitment checks were in place to help ensure staff employed were suitable to care for people. However, the provider did not complete all the required pre-employment checks on staff who had worked in care before, to ensure their suitability for the role. This meant there was a risk that people might receive care from unsuitable staff.”

“Right Support - Staff ensured they communicated and shared information with people in a way they could understand. People were encouraged to maintain relationships with family and friends. Governance systems and audits were not always effective in identifying or addressing areas for improvement. New staff were not always recruited robustly.”

“Right Care - Staff followed current best practice guidelines regarding infection prevention and control. People told us staff were kind and caring and staff protected their privacy and dignity.”

“Right culture–Governance systems were not robust. People spoke highly of staff members. Staff understood people and their needs well, and escalated concerns appropriately. Staff received safeguarding training and understood their roles in protecting people from the risk of abuse or avoidable harm. The provider raised and escalated safeguarding’s and concerns about people’s needs effectively.”

“The provider told us they would take action to address concerns raised during the inspection. We have asked the provider for an action plan in response to the concerns found at this assessment.”