# Leicester

*Operated by 3 Star Health Care Limited.*

Leicester is a CQC-regulated home-care agency in Leicester.

## CQC Ratings

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

Rating published: 09/06/2023

## Practical info

- Postcode: LE4 7BZ
- Registered manager: Ncube, Nomusa
- Local authority: Leicester
- Region: East Midlands
- City: Leicester
- Last CQC check: 09/Jun/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Unannounced spot and competency checks on staff were completed by the management team.
  - Published: 2023-06-20
- Finding
  - Evidence: The registered manager promoted a positive, inclusive culture and was receptive to feedback.
  - Published: 2023-06-20
- Finding
  - Evidence: Staff felt fully supported in their role and received feedback through supervisions.
  - Published: 2023-06-20
- Finding
  - Evidence: Infection prevention and control practice was followed by staff, including correct use of PPE.
  - Published: 2023-06-20
- Finding
  - Evidence: People were supported with their medicines safely and staff had medication training with competency assessed.
  - Published: 2023-06-20
- Finding
  - Evidence: Staff were knowledgeable in safeguarding procedures and aware of how to escalate concerns.
  - Published: 2023-06-20
- Finding
  - Evidence: Staff were recruited safely with criminal record checks, identity and right to work checks completed.
  - Published: 2023-06-20
- Finding
  - Evidence: People told us they felt safe with the staff and the care provided.
  - Published: 2023-06-20
- **person_centred_care** _(minor)_
  - Evidence: A person's religion and culture was not accurately reflected. This was raised with the registered manager and they agreed to follow this up.
  - Published: 2023-06-20
- **medication_management** _(moderate)_
  - Evidence: Staff had recorded medicines were prompted despite no reference made in the care plan.
  - Published: 2023-06-20
- **staff_training** _(moderate)_
  - Evidence: The training matrix highlighted where staff training was due to expire or had expired. Training was booked for some staff but not all.
  - Published: 2023-06-20
- **record_keeping** _(critical)_
  - Evidence: A body map detailed the different sites where the skin damage had occurred, but these were not dated nor detailed any follow-up actions.
  - Published: 2023-06-20
- **incident_learning** _(moderate)_
  - Evidence: Accidents and incidents were analysed individually, however there was limited oversight to identify any trends.
  - Published: 2023-06-20
- **governance** _(critical)_
  - Evidence: The provider's oversight systems and processes were not effectively used to monitor the quality of service being provided and to drive improvements.
  - Published: 2023-06-20
- **care_planning** _(critical)_
  - Evidence: Care plans were not always kept up to date and contain sufficient up to date guidance for staff to follow to keep people safe.
  - Published: 2023-06-20

### safe

- Finding
  - Learning lessons when things go wrong
  - Published: 2023-06-20
- Finding
  - Preventing and controlling infection
  - Published: 2023-06-20
- Finding
  - Staffing and recruitment
  - Published: 2023-06-20
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-06-20
- Finding
  - Using medicines safely
  - Published: 2023-06-20
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-06-20

### well_led

- Finding
  - Working in partnership with others
  - Published: 2023-06-20
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2023-06-20
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2023-06-20
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-06-20
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2023-06-20

## 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/1-2961808226

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