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Inspection Summary

Overall summary & rating


Updated 19 May 2018

This inspection took place on 11 April 2018 and was announced. We gave the provider 48 hours’ notice that we would be visiting the service. This was because the service provides domiciliary care to people living in their own homes and we wanted to make sure staff would be available. At the last inspection on 19 January 2017, we found that the provider was ‘requires improvement’ under the key questions of safe, effective, caring and well-led and did not meet all the legal requirements. During this inspection, we found there had been a significant improvement however, further improvement was still required.

Excellence Healthcare is a domiciliary care agency registered to provide personal care to people living in their own homes. At the time of the inspection the service supported nine people.

The registered manager was also the provider. 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.

At our previous inspection in January 2017 we rated the service as 'Requires Improvement' as the service was not always safe because staff did not consistently have the information they required to ensure that people were protected against identified risks. It was not always clear whether people were receiving their medicines as prescribed. People's rights were not always protected because the provider was not aware of their responsibilities to ensure that care was provided lawfully. The provider had failed to respond to some of the improvements that were recommended at our inspection in January 2016. The provider had some management systems in

place to assess and monitor the quality of the service provided to people. However, some of these were not always used effectively to manage risks and to identify where improvements were needed. On this inspection we found improvements had been made and although there was some further improvement to be made, the overall rating for the service was now Good.

The provider had improved their quality assurance systems. However, further improvement was required with the consistency of updating and reviewing care plans and risk assessments, that ensured they were up to date, accurate and reflective of people’s needs and choices. The provider had taken steps to ensure they were kept up to date with current legislative practices however, their knowledge around protecting people’s rights required further improvement.

People felt safe in their homes with staff. Relatives were confident their family members were kept safe. Staff knew what action they would take if they thought a person was at risk of harm. Risks to people were assessed and people were supported by staff that was provided with guidance on how to manage people’s specific medical conditions.

People were supported by sufficient numbers of staff that had been safely recruited. Where appropriate, people were supported with their medicines by staff that had received training. Staff members were equipped with sufficient personal protection equipment to reduce the risk of infection and cross contamination when supporting people with their personal care.

Staff were trained to ensure that they had the skills to support people effectively. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were able to make decisions about how they wanted to receive support to ensure their health needs were met. Where appropriate, people required assistance to eat and drink. Timely referrals were made to health and social care professionals when people’s needs changed.

People had a small team of staff who provided their support and had caring relationships with them. C

Inspection areas



Updated 19 May 2018

The service was safe.

People felt safe with the staff that provided them with support. Systems were in place to protect people from the risk of harm and staff knew how to report any suspicions of abuse. Where appropriate, investigations were conducted in partnership with other agencies.

People were safeguarded from the risk of harm because risk assessments were in place to protect them. People were supported by sufficient numbers of staff that were recruited safely, to ensure that they were suitable to work with people in their own homes.

People were supported by staff to take their medicines as prescribed, where required. People were protected from infection and cross contamination because staff members were provided with and used appropriate personal protective equipment.



Updated 19 May 2018

The service was effective.

People�s needs were assessed and they were supported by staff that had the skills and knowledge to assist them.

People were supported to access additional medical support in a timely manner when their needs changed.

People were happy with the care provided by staff and were supported to make decisions and choices about their care.



Updated 19 May 2018

The service was caring.

People were supported by staff who were kind and respectful.

People�s independence was promoted as much as possible and staff supported people to make decisions about the care they received.

People�s privacy and dignity were maintained.



Updated 19 May 2018

The service was responsive.

People received care and support that was individualised to their needs, because staff members knew people well.

People knew how to raise concerns about the service they had received and were confident that these would be addressed appropriately.


Requires improvement

Updated 19 May 2018

The service was not consistently well-led.

Improved quality assurance and audit processes were in place to monitor the service to ensure people received a quality service, but they required further improvement. People were encouraged to provide feedback on the quality of the service they received.

People and their relatives were happy with the quality of the service.

Staff felt supported by the provider and involved in developing the service.

The provider worked in partnership with other services to ensure they supported people in a safe and consistent way.