# Extra Hands of Heacham Limited - Broadland Office

*Operated by Extra Hands of Heacham Ltd.*

Extra Hands of Heacham Limited - Broadland Office is a CQC-regulated home-care agency in Norwich.

## CQC Ratings

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

Rating published: 12/06/2021

## Practical info

- Postcode: NR10 3JU
- Registered manager: Claxton, Hayley
- Local authority: Norfolk
- Region: East
- City: Norwich
- Last CQC check: 12/Jun/2021 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Complaints were investigated and resolved promptly; people and relatives felt involved and informed.
  - Published: 2021-10-30
- Finding
  - Evidence: Comprehensive staff training including safeguarding, first aid, and pressure care management.
  - Published: 2021-10-30
- Finding
  - Evidence: Incidents and accidents were investigated with action taken to mitigate recurrence.
  - Published: 2021-10-30
- Finding
  - Evidence: Effective infection control measures in place including full PPE use during care visits.
  - Published: 2021-10-30
- Finding
  - Evidence: Strong positive working culture with good teamwork; staff felt able to raise concerns and management were approachable.
  - Published: 2021-10-30
- Finding
  - Evidence: People received person-centred, responsive care; staff were knowledgeable about individual needs, interests and health conditions.
  - Published: 2021-10-30
- Finding
  - Evidence: Staff were recruited safely and cared for a consistent group of people they knew well, mitigating risks from incomplete records.
  - Published: 2021-10-30
- **communication_with_families** _(minor)_
  - Evidence: Care plans did not fully cover people's communication requirements, for example, where they referred to a person having problems with communication, there was no further guidance
  - Published: 2021-10-30
- **governance** _(critical)_
  - Evidence: Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17.
  - Published: 2021-10-30
- **care_planning** _(minor)_
  - Evidence: Records did not show that end of life wishes had been considered as part of a person's care planning.
  - Published: 2021-10-30
- **care_planning** _(moderate)_
  - Evidence: There were no specific care plans or risk assessments for people with a history of falls or pressure ulcers.
  - Published: 2021-10-30
- **record_keeping** _(critical)_
  - Evidence: for two consecutive months allergies had been missed off a medicine administration record (MAR), which had been found on the audit. Action was not taken to ensure the same recording issue did not recur.
  - Published: 2021-10-30
- **record_keeping** _(critical)_
  - Evidence: There were no care plans or risk assessments relating to people's mental health where they had a history of depression, or relating to existing health conditions such as stroke, arthritis, diabetes, dementia
  - Published: 2021-10-30
- **medication_management** _(minor)_
  - Evidence: There were not body maps in place for pain patches, which is best practice.
  - Published: 2021-10-30

### responsive

- Finding
  - End of life care and support
  - Published: 2021-10-30
- Finding
  - Improving care quality in response to complaints or concerns
  - Published: 2021-10-30
- Finding
  - Meeting people's communication needs
  - Published: 2021-10-30
- Finding
  - Planning personalised care to ensure people have choice and control
  - Published: 2021-10-30

### safe

- Finding
  - Learning lessons when things go wrong
  - Published: 2021-10-30
- Finding
  - Preventing and controlling infection
  - Published: 2021-10-30
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2021-10-30
- Finding
  - Staffing and recruitment
  - Published: 2021-10-30
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2021-10-30
- Finding
  - Using medicines safely
  - Published: 2021-10-30

### well_led

- Finding
  - Working in partnership with others
  - Published: 2021-10-30
- Finding
  - Continuous learning and improving care
  - Published: 2021-10-30
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2021-10-30
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2021-10-30
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2021-10-30
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2021-10-30

## 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/1-122339571

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