# Nottingham Mencap Short Breaks Service

*Operated by Nottingham Mencap.*

Nottingham Mencap Short Breaks Service is a CQC-regulated home-care agency in Nottingham.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Good |
| Safe | Good |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Good |

Rating published: 05/07/2022

## Practical info

- Postcode: NG3 2ET
- Registered manager: Vogel, Susan
- Local authority: Nottingham
- Region: East Midlands
- City: Nottingham
- Last CQC check: 05/Jul/2022 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Feedback from people and relatives was recorded and used to drive improvement.
  - Published: 2024-06-21
- Finding
  - Evidence: Staff wellbeing was actively supported and monitored during the COVID-19 pandemic.
  - Published: 2024-06-21
- Finding
  - Evidence: Person-centred care promoted dignity, independence and positive outcomes for people.
  - Published: 2024-06-21
- Finding
  - Evidence: People, relatives and staff praised the registered manager's caring and supportive approach.
  - Published: 2024-06-21
- Finding
  - Evidence: People had a small, consistent team of staff; relatives confirmed carers always arrived on time.
  - Published: 2024-06-21
- Finding
  - Evidence: Staff were recruited safely with appropriate pre-employment suitability checks completed.
  - Published: 2024-06-21
- Finding
  - Evidence: Robust infection control procedures in place, including COVID-19 adaptations in line with government guidelines.
  - Published: 2024-06-21
- Finding
  - Evidence: People felt safe and staff were knowledgeable about people's needs; a person said staff help them stay safe.
  - Published: 2024-06-21
- **safeguarding** _(moderate)_
  - Evidence: policies did not include reference to ensuring the CQC were notified of concerns... Whistleblowing policy only referred to internal reporting procedures.
  - Published: 2024-06-21
- **complaints_handling** _(minor)_
  - Evidence: complaint policy did not contain details of The Local Government and Social Care Ombudsman whom people could refer their complaint if they were not satisfied.
  - Published: 2024-06-21
- **incident_learning** _(moderate)_
  - Evidence: it did not include a reminder to inform the CQC of a notifiable incident. The registered manager told us they would amend the form to include these areas.
  - Published: 2024-06-21
- **governance** _(moderate)_
  - Evidence: nominated individual and manager did not always have a thorough understanding of the regulatory requirements of their role.
  - Published: 2024-06-21
- **staff_training** _(moderate)_
  - Evidence: training records stated that staff had not received formal training to assist them with safely managing these situations. This could place people's safety at risk.
  - Published: 2024-06-21
- **care_planning** _(moderate)_
  - Evidence: plans to evacuate people from their homes in case of a fire were not individualised and did not consider their ability to understand the danger.
  - Published: 2024-06-21

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2024-06-21
- Finding
  - Using medicines safely
  - Published: 2024-06-21
- Finding
  - Staffing and recruitment
  - Published: 2024-06-21
- Finding
  - Learning lessons when things go wrong
  - Published: 2024-06-21
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2024-06-21
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2024-06-21

### well_led

- Finding
  - Working in partnership with others
  - Published: 2024-06-21
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2024-06-21
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2024-06-21
- Finding
  - How the provider understands and acts on duty of candour responsibility
  - Published: 2024-06-21
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2024-06-21
- Finding
  - Working in partnership with others
  - Published: 2024-06-21
- Finding
  - Continuous learning and improving care
  - Published: 2024-06-21
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2024-06-21
- Finding
  - Managers and staff being clear about their roles and understanding quality performance
  - Published: 2024-06-21
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2024-06-21

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-115772831

HomeCare Compass is an independent guide and is not affiliated with the CQC.