Daily Comfort Healthcare Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service continued to be in breach of legal regulation in relation to good governance. The provider’s risk and quality monitoring systems remained ineffective.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.
We identified continued breaches of the legal regulations and concerns in areas such as safe care, recruitment and consent records as well as ongoing concerns regarding governance. Leaders had not independently identified and acted on these concerns prior to our assessment. This meant some development was needed in their skills and knowledge to lead effectively.
The registered manager had achieved leadership qualifications as well as train the trainer to be able to train staff face to face. Staff told us the registered manager was available to drive staff to calls, and they were able to contact them when needed. Senior staff had received appropriate training and ongoing development programmes relevant to their roles.

People did not always feel they could speak up and that their voice would be heard.
Staff told us they felt comfortable in speaking up and raising issues to senior staff. However, there was no evidence of where issues had been raised, and appropriate actions taken. Although the registered manager held team meetings online, we could not check their contents or who had attended as these were not provided. The provider had not used other methods such as surveys to capture staff feedback. Anonymous surveys are a good way of capturing the culture and morale of a service and staff. The provider had a whistleblowing policy in place and staff had received training in line with this policy. Staff knew who and what to report both inside and outside of the service and felt able to do so. There was no complaints log in place to show how the provider responded to complaints. The registered manager told us they would act to address concerns when known. People told us where staff had not been compatible with people, the provider had accepted this and replaced or improved the staffing for them.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
The provider had appropriate policies in place and staff received training in equality and diversity. The registered manager told us there were currently no staff employed who needed reasonable adjustments due to their protected characteristics. These could be discussed during supervisions if needed.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s action plan in response to shortfalls we found at the last inspection had not resulted in the required improvements. The provider’s risk and quality monitoring systems continued to be ineffective. Regular audits had not taken place for key aspects of the service. Where they had been completed, such as medicine audits, they had not identified or assessed risks relating to the use of emollient creams. The provider had not identified the shortfalls we found in relation to people’s risk assessments and consent records. This put people at increased risk of receiving unsafe care.
Records relating to recruitment and all areas of service management and people’s care were not made available to CQC upon request. This meant we had very limited assurance around how regulations were being met.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
The registered manager had worked with an external consultant to produce an action plan from the previous assessment with areas of improvement. However, they were not able to evidence where this had been completed. Although the provider was motivated to learn and improve the service for people, improvements were limited by the lack of established risk and quality monitoring systems. This meant they might not always be aware of shortfalls to enable prompt improvement and learning.
The provider was unable to show us any evidence of learning from incidents, complaints, or feedback from people or staff. There was no incident or complaints log available during the inspection. Other information such as team meetings, where learning and quality improvements could be discussed with staff, were not available to the inspector to review.