# Domiciliary Care Agency East Area

*Operated by Achieve Together Limited.*

Domiciliary Care Agency East Area is a CQC-regulated home-care agency in Spalding.

## CQC Ratings

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

Rating published: 24/06/2022

## Practical info

- Postcode: PE12 8LE
- Registered manager: Mercer, Emily
- Local authority: Lincolnshire
- Region: East Midlands
- City: Spalding
- Last CQC check: 28/Sep/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: End-of-life care wishes were documented and people's relatives were involved where capacity was lacking.
  - Published: 2023-10-13
- Finding
  - Evidence: The provider worked in partnership with relatives, representatives and health and social care professionals.
  - Published: 2023-10-13
- Finding
  - Evidence: People were supported to access specialist health and social care support in the community.
  - Published: 2023-10-13
- Finding
  - Evidence: At Helena Services, The Stables and Kings Ripton Services, staff and management learnt from complaints, incidents and audits.
  - Published: 2023-10-13
- Finding
  - Evidence: Safeguarding incidents were investigated and reported to the local authority and CQC when appropriate.
  - Published: 2023-10-13
- Finding
  - Evidence: People's care plans were detailed and included information about individual risks, needs and preferences.
  - Published: 2023-10-13
- Finding
  - Evidence: Staff communicated with people in ways that met their individual communication needs.
  - Published: 2023-10-13
- Finding
  - Evidence: Staff were recruited safely with appropriate pre-employment checks carried out before staff started working.
  - Published: 2023-10-13
- **record_keeping** _(minor)_
  - Evidence: Medicines stock levels and records were not consistently checked by management. We were told medicines audits were not available for Willoughby Services.
  - Published: 2023-10-13
- **incident_learning** _(moderate)_
  - Evidence: Audits of quality and safety were not always completed as they should have been, which meant that lessons were not always learnt, and improvements made in a timely way.
  - Published: 2023-10-13
- **person_centred_care** _(moderate)_
  - Evidence: The level of person-centred care that people received was not consistent across all of the supported living settings.
  - Published: 2023-10-13
- **complaints_handling** _(moderate)_
  - Evidence: We reviewed 3 complaints that had been received by Willoughby services. Only one of the 3 had been investigated and responded to in line with the provider's policy.
  - Published: 2023-10-13
- **leadership** _(moderate)_
  - Evidence: There had been numerous changes in the management of the service in the previous 12 months...at service manager level, manager level and regional manager level.
  - Published: 2023-10-13
- **governance** _(critical)_
  - Evidence: The provider had failed to assess, monitor and improve the quality and safety of the service. This was breach of regulation 17 (2) of the Health and Social Care Act 2008.
  - Published: 2023-10-13
- **infection_control** _(moderate)_
  - Evidence: Some areas of Willoughby Services were not clean, including a mouldy shower curtain, unclean bedding and a damp smelling bathroom with stained flooring.
  - Published: 2023-10-13
- **staff_training** _(critical)_
  - Evidence: Not all staff had completed the training necessary to meet people's needs...positive behaviour support, epilepsy awareness, specialist epilepsy medication, dysphagia and autism training.
  - Published: 2023-10-13

### responsive

- Finding
  - End of life care and support
  - Published: 2023-10-13
- Finding
  - Improving care quality in response to complaints or concerns
  - Published: 2023-10-13
- Finding
  - Meeting people's communication needs
  - Published: 2023-10-13
- Finding
  - Planning personalised care; Supporting relationships; Support to follow interests and activities
  - Published: 2023-10-13

### safe

- Finding
  - Learning lessons when things go wrong
  - Published: 2023-10-13
- Finding
  - Using medicines safely
  - Published: 2023-10-13
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-10-13
- Finding
  - Assessing risk, safety monitoring and management; Preventing and controlling infection
  - Published: 2023-10-13
- Finding
  - Staffing and recruitment
  - Published: 2023-10-13

### well_led

- Finding
  - Working in partnership with others
  - Published: 2023-10-13
- Finding
  - Duty of candour
  - Published: 2023-10-13
- Finding
  - Promoting a positive, person-centred, open and inclusive culture
  - Published: 2023-10-13
- Finding
  - Engaging and involving people, the public and staff
  - Published: 2023-10-13
- Finding
  - Managers and staff roles, quality performance, risks and regulatory requirements; Continuous learning
  - Published: 2023-10-13

## 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/1-2440811444

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