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Excel Care Management Services Ltd Good

Inspection Summary

Overall summary & rating


Updated 13 July 2018

We carried out an announced inspection of Excel Care Management on 21 and 22 May 2018. We also gathered the views of people who used the service, their relatives and staff members via telephone calls and emailed questionnaires between the 22 May 2018 and 05 June 2018. Although the service had moved office from Atherton to Leigh since our last inspection, the service history was not affected because care and support is provided to people in their own home.

Excel Care Management is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to people living with dementia, older people, children and people with a physical disability or autistic sensory impairment. The service is a member of the local authorities ‘Ethical Community Services Framework’ and was awarded the contract for provision of care in Leigh. At the time of the inspection, there were 129 people receiving a service from Excel Care Management.

The service was last inspected in March 2017, when we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to good governance (two parts of the regulation) and staffing. Following this inspection, the service was rated as requires improvement overall and in the key lines of enquiry (KLOE's); safe, effective, responsive and well-led. The service was rated as good in caring.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; safe, effective, responsive and well-led to at least good. The service has been provided ongoing support and monitoring by the local authority through the ‘Ethical Framework’. We reviewed the progress the provider had made as part of this inspection and found that all the breaches identified at our last inspection had been fully addressed. At this inspection the service was found to be complaint with all the regulations.

At the time of the inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

All the people and their relatives we spoke with said they felt the service was safe. We saw there were suitable safeguarding policies and procedures in place. Staff had all received training in safeguarding vulnerable adults and demonstrated a good understanding of how to report both safeguarding and whistleblowing concerns.

We saw effective recruitment procedures remained in place to ensure staff working for the service met the required standards. The registered manager had also implemented pre-interview telephone screening to ensure staff had the required values before progressing to formal interview.

At our last inspection we identified concerns with documentation relating to the management of medicines. At this inspection, we confirmed medicines were managed safely, all guidance to support the safe administration of medicines were in place and audits completed timely to ensure signature omissions had been identified and addressed.

The provider had appropriate assessments in place which were reflective of people’s needs and provided guidance for staff on the measures needed to reduce risks. There was an effective system in place to manage accidents and incidents, and to reduce the likelihood of re-occurrence.

Since our previous inspection, staff had received a comprehensive training programme and were working towards the care certificate with an identified timeframe for completion. Staff had a personal development plan (PDP), received quarterly supervision and staff in post over a year had completed an annual appraisal.

The s

Inspection areas



Updated 13 July 2018

The service was safe

Risks were identified and appropriate control measures in place to mitigate the risk from occurring.

There were appropriate recruitment checks in place and people were protected from the risk of harm and abuse.

People�s medicines were managed safely by staff who had received appropriate training. Regular audits were completed to make sure shortfalls were identified and action taken to prevent re-occurrence.



Updated 13 July 2018

The service was effective

Staff received an induction and training that was aligned with the care certificate.

Staff were supported in their role and had a personal development plan (PDP), regular supervision and an appraisal of their work.

The service was working within the principles of the Mental Capacity Act 2005. People had consented to their care or decisions had been made in their best interest by their next of kin or legal representative.



Updated 13 July 2018

The service was caring

People and their relatives were complimentary about the care staff and the care they received.

People�s dignity was maintained and their independence promoted.

People�s confidentially was maintained and this requirement was a regular topic of discussion during supervision and staff meetings.



Updated 13 July 2018

The service was responsive

People received personalised care that was responsive to their needs.

Social inclusion was promoted and people were encouraged to engage in activities of interest.

There was a clear complaints process in place and we saw complaints had been responded to timely.



Updated 13 July 2018

The service was well-led

There was a clear commitment amongst the management team to integrate with the local community and to deliver high quality care.

The provider was establishing community links and founded a charity for the local community to support better outcomes for people.

Governance systems ensured care and support was provided properly and gaps or errors had been identified and addressed through the audit process.