# Voyage (DCA) Gloucester

*Operated by Fox Elms Care Limited.*

Voyage (DCA) Gloucester is a CQC-regulated home-care agency in Gloucester.

## CQC Ratings

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

Rating published: 21/07/2022

## Practical info

- Postcode: GL2 5EN
- Registered manager: Withers, Amy
- Local authority: Gloucestershire
- Region: South West
- City: Gloucester
- Last CQC check: 21/Jul/2022 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: The provider understood duty of candour responsibilities and apologised to people when things went wrong.
  - Published: 2022-08-04
- Finding
  - Evidence: People with swallowing difficulties were supported using the IDDSI Framework, with food and drinks prepared safely.
  - Published: 2022-08-04
- Finding
  - Evidence: A new senior management team implemented a service improvement plan prior to inspection and had made considerable progress.
  - Published: 2022-08-04
- Finding
  - Evidence: The service worked within the principles of the Mental Capacity Act and appropriate DoLS authorisations were in place.
  - Published: 2022-08-04
- Finding
  - Evidence: Recruitment was conducted safely, including DBS checks and references before staff worked with people.
  - Published: 2022-08-04
- Finding
  - Evidence: Staff followed STOMP principles, ensuring behaviour was not controlled by excessive or inappropriate use of medicines.
  - Published: 2022-08-04
- Finding
  - Evidence: Staff understood safeguarding responsibilities and could describe types of abuse, signs of concern, and reporting procedures.
  - Published: 2022-08-04
- **incident_learning** _(moderate)_
  - Evidence: We saw evidence that encouraged reflective practice following medicines incidents however, we did not see evidence to prevent future occurrences.
  - Published: 2022-08-04
- **infection_control** _(minor)_
  - Evidence: Staff did not consistently wear PPE in line with the guidance and providers policy.
  - Published: 2022-08-04
- **communication_with_families** _(moderate)_
  - Evidence: One relative said, 'I haven't seen the care plan and there's quite a few times that the phone hasn't worked for weeks and weeks.'
  - Published: 2022-08-04
- **leadership** _(moderate)_
  - Evidence: Staff did not consistently know and understand the provider's vision and values. One staff member said, 'I don't know what [the Provider] wants and I don't know what they stand for.'
  - Published: 2022-08-04
- **staffing_levels** _(moderate)_
  - Evidence: people had not always received correct staffing levels or expertise from staff who knew them well.
  - Published: 2022-08-04
- **care_planning** _(critical)_
  - Evidence: People who have a diagnosis of epilepsy did not always have clear guidelines and protocols for staff to follow to support them safely.
  - Published: 2022-08-04
- **medication_management** _(moderate)_
  - Evidence: for one person we could not see the record to support the decision to give medicine covertly.
  - Published: 2022-08-04
- **medication_management** _(moderate)_
  - Evidence: we could not be assured that other medicines information in care records was always up to date or readily available when needed.
  - Published: 2022-08-04
- **record_keeping** _(critical)_
  - Evidence: records relating to people's care were not always comprehensive and up-to-date. This placed people at risk of harm.
  - Published: 2022-08-04
- **governance** _(critical)_
  - Evidence: systems were either not in place or robust enough to demonstrate the service was effectively managed. This placed people at risk of harm. This was a breach of regulation 17.
  - Published: 2022-08-04
- Finding
  - Evidence: Supportive induction process praised by new staff members.
  - Published: 2021-10-30
- Finding
  - Evidence: Service worked closely with GPs, district nurses and other health professionals to support people's needs.
  - Published: 2021-10-30
- Finding
  - Evidence: Provider demonstrated openness and duty of candour throughout the inspection.
  - 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
  - Staffing and recruitment
  - Published: 2021-10-30
- Finding
  - Using medicines safely
  - Published: 2021-10-30
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2021-10-30
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2021-10-30

### well_led

- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2021-10-30
- Finding
  - Continuous learning and improving care
  - Published: 2021-10-30
- Finding
  - Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements
  - Published: 2021-10-30
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - 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/1-1400551308

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