# 81 Wood Lane

*Operated by Shephards Care Services Ltd.*

81 Wood Lane is a CQC-regulated home-care agency in Birmingham.

## CQC Ratings

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

Rating published: 09/12/2021

## Practical info

- Postcode: B32 4AD
- Registered manager: Ketema Tefera, Tigist
- Local authority: Birmingham
- Region: West Midlands
- City: Birmingham
- Last CQC check: 21/Sep/2022 - 00:00

## Inspection findings

### effective

- Finding
  - Ensuring consent to care and treatment in line with law and guidance
  - Published: 2022-09-21
- Finding
  - Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier lives, access healthcare services and support
  - Published: 2022-09-21
- Finding
  - Assessing people's needs and choices; delivering care in line with standards, guidance and the law
  - Published: 2022-09-21
- Finding
  - Staff support: induction, training, skills and experience
  - Published: 2022-09-21

### Other

- Finding
  - Evidence: Service no longer in Special Measures
  - Published: 2022-09-21
- Finding
  - Evidence: Provider and director were open and honest, demonstrating willingness to improve
  - Published: 2022-09-21
- Finding
  - Evidence: Surveys introduced to seek feedback from people and relatives
  - Published: 2022-09-21
- Finding
  - Evidence: MAR sheets introduced and completed accurately for regular medicines
  - Published: 2022-09-21
- Finding
  - Evidence: Provider worked in partnership with healthcare professionals such as district nurses and doctors
  - Published: 2022-09-21
- Finding
  - Evidence: Positive feedback from people using the service ('staff are smashing', 'very pleased with the service')
  - Published: 2022-09-21
- Finding
  - Evidence: Consistent staff team who knew people well, providing continuity of care
  - Published: 2022-09-21
- Finding
  - Evidence: Staff received safeguarding training and knew how to escalate concerns
  - Published: 2022-09-21
- Finding
  - Evidence: Sufficient staffing levels with people reporting staff always attended on time
  - Published: 2022-09-21
- Finding
  - Evidence: Improvements made to safe recruitment practices including full employment history and DBS checks, no longer in breach of Regulation 19
  - Published: 2022-09-21
- **consent_capacity** _(minor)_
  - Evidence: Staff had not received training around the Mental Capacity Act 2005.
  - Published: 2022-09-21
- **record_keeping** _(moderate)_
  - Evidence: Audits had not identified that some review dates for documents had passed.
  - Published: 2022-09-21
- **governance** _(critical)_
  - Evidence: the systems to monitor the quality and safety of the service had failed to identify these areas of concern. This was a continued breach of Regulation 17 (Good Governance)
  - Published: 2022-09-21
- **supervision_appraisal** _(critical)_
  - Evidence: there was no record of staff supervisions that had taken place... informal supervision took place but that this was not recorded.
  - Published: 2022-09-21
- **staff_competency** _(moderate)_
  - Evidence: Following training there was no formal competency sign off and whilst some areas of care had a competency assessment, others did not.
  - Published: 2022-09-21
- **staff_training** _(moderate)_
  - Evidence: Staff had not received training around the Mental Capacity Act 2005.
  - Published: 2022-09-21
- **care_planning** _(moderate)_
  - Evidence: the risk of bed rails to one person had not been fully considered. In addition, risk assessments around healthcare conditions such as diabetes needed to become more focussed on the individual person's needs
  - Published: 2022-09-21

### safe

- Finding
  - Learning lessons when things go wrong
  - Published: 2022-09-21
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2022-09-21
- Finding
  - Staffing and recruitment
  - Published: 2022-09-21
- Finding
  - Assessing risk, safety monitoring and management; Using medicines safely; Preventing and controlling infection
  - Published: 2022-09-21

### well_led

- Finding
  - Working in partnership with others
  - Published: 2022-09-21
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2022-09-21
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2022-09-21
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2022-09-21
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving care
  - Published: 2022-09-21

## 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/1-9012280065

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