# Mencap - Trowbridge

*Operated by Royal Mencap Society.*

Mencap - Trowbridge is a CQC-regulated home-care agency in Trowbridge.

## CQC Ratings

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

Rating published: 06/10/2023

## Practical info

- Postcode: BA14 0XG
- Registered manager: Lamb, Joanna
- Local authority: Wiltshire
- Region: South West
- City: Trowbridge
- Last CQC check: 06/Oct/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Relatives were sent questionnaires and issues raised were acted upon.
  - Published: 2023-10-12
- Finding
  - Evidence: Incident learning was reviewed at monthly managers meetings and cascaded to staff.
  - Published: 2023-10-12
- Finding
  - Evidence: Infection prevention and control measures were effective and policies up to date.
  - Published: 2023-10-12
- Finding
  - Evidence: Robust recruitment systems and safe interviewing practices were in place.
  - Published: 2023-10-12
- Finding
  - Evidence: A new registered manager demonstrated understanding of least restrictive and person-centred support.
  - Published: 2023-10-12
- Finding
  - Evidence: All homes other than one used E-MARs which were reviewed and found to be managing medicines safely.
  - Published: 2023-10-12
- Finding
  - Evidence: The service was working within the principles of the Mental Capacity Act with appropriate DoLS authorisations.
  - Published: 2023-10-12
- Finding
  - Evidence: Staff received regular safeguarding training and could explain what to do if someone was at risk.
  - Published: 2023-10-12
- Finding
  - Evidence: People had comprehensive care and support plans in place.
  - Published: 2023-10-12
- Finding
  - Evidence: People and relatives reported feeling safe and happy with the support provided.
  - Published: 2023-10-12
- **consent_capacity** _(minor)_
  - Evidence: The provider had not always recorded they had consulted and involved people in decisions, such as choices around healthy eating.
  - Published: 2023-10-12
- **record_keeping** _(moderate)_
  - Evidence: One home had handwritten Medicine Administration Records (MAR) due to the high level of agency staff who could not access their electronic medicine records (E-MAR) system.
  - Published: 2023-10-12
- **governance** _(moderate)_
  - Evidence: audits had not identified the issues we found on inspection in one home around medicines. There was less oversight of the handwritten records.
  - Published: 2023-10-12
- **staffing_levels** _(moderate)_
  - Evidence: There was a high level of agency staff being used at one home... agency staff were not insured to drive these cars. This led to people not having as high a quality of life.
  - Published: 2023-10-12
- **staff_competency** _(moderate)_
  - Evidence: Agency staff had an introduction to the home via an induction but the service manager had not ensured competency assessment had been completed.
  - Published: 2023-10-12
- **care_planning** _(moderate)_
  - Evidence: People were not always supported safely to reduce their risk of pressure ulcers... There were no risk assessments in place to help manage risks in relation to pressure ulcers.
  - Published: 2023-10-12
- **medication_management** _(critical)_
  - Evidence: medicine patches were not being administered in line with manufactures instructions to rotate the patch. There was no evidence that staff were checking regularly that the patch was still in place.
  - Published: 2023-10-12
- **medication_management** _(critical)_
  - Evidence: People's allergies were not recorded on the handwritten MAR sheets. This meant that people could be put at risk of being given medicines they were allergic to.
  - Published: 2023-10-12

### safe

- Finding
  - Learning lessons when things go wrong
  - Published: 2023-10-12
- Finding
  - Preventing and controlling infection
  - Published: 2023-10-12
- Finding
  - Staffing and recruitment
  - Published: 2023-10-12
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-10-12
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-10-12
- Finding
  - Using medicines safely
  - Published: 2023-10-12

### well_led

- Finding
  - Continuous learning and improving care
  - Published: 2023-10-12
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2023-10-12
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2023-10-12
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2023-10-12
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-10-12

## 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/1-4076151755

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