# Royal Mencap Society - Norfolk Domiciliary Care Agency

*Operated by Royal Mencap Society.*

Royal Mencap Society - Norfolk Domiciliary Care Agency is a CQC-regulated home-care agency in Thetford.

## CQC Ratings

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

Rating published: 20/08/2022

## Practical info

- Postcode: IP24 2DL
- Registered manager: Griffiths, Karen
- Local authority: Norfolk
- Region: East
- City: Thetford
- Last CQC check: 20/Aug/2022 - 00:00

## Inspection findings

### caring

- Finding
  - Respecting and promoting people's privacy, dignity and independence
  - Published: 2022-08-20
- Finding
  - Supporting people to express their views and be involved in making decisions about their care
  - Published: 2022-08-20
- Finding
  - Ensuring people are well treated and supported; respecting equality and diversity
  - Published: 2022-08-20

### effective

- Finding
  - Supporting people to eat and drink enough to maintain a balanced diet
  - Published: 2022-08-20
- Finding
  - Staff support: induction, training, skills and experience
  - Published: 2022-08-20
- Finding
  - Assessing people's needs and choices; delivering care in line with standards, guidance and the law
  - Published: 2022-08-20
- Finding
  - Ensuring consent to care and treatment in line with law and guidance
  - Published: 2022-08-20

### Other

- Finding
  - Evidence: Established leadership structure with experienced and well-regarded registered manager
  - Published: 2022-08-20
- Finding
  - Evidence: People supported to maintain contact with family and engage in varied activities and community life
  - Published: 2022-08-20
- Finding
  - Evidence: Staff treated people with compassion, dignity and respect; diverse workforce reflecting service users
  - Published: 2022-08-20
- Finding
  - Evidence: Person-centred care plans giving good overview of needs and preferences
  - Published: 2022-08-20
- Finding
  - Evidence: Medicines audited regularly with annual reviews and STOMP principles followed
  - Published: 2022-08-20
- Finding
  - Evidence: Safeguarding systems and training in place; staff knew how to report concerns
  - Published: 2022-08-20
- Finding
  - Evidence: Staff and management pulled together during COVID-19 to ensure people's commissioned hours were provided
  - Published: 2022-08-20
- **communication_with_families** _(minor)_
  - Evidence: Relatives told us Mencap had not asked them for regular input or feedback about the quality of the service provided.
  - Published: 2022-08-20
- **care_planning** _(moderate)_
  - Evidence: we were unable to see evidence of how people were actively involved in planning and reviewing their needs... care and support plans did not record regular outcomes for people.
  - Published: 2022-08-20
- **medication_management** _(minor)_
  - Evidence: prior to this incident the provider had not considered risks associated with aspiration and medicines for those on a softer diet.
  - Published: 2022-08-20
- **end_of_life_care** _(minor)_
  - Evidence: Staff had not received end of life training and people's advance wishes were not always recorded.
  - Published: 2022-08-20

### responsive

- Finding
  - End of life care and support
  - Published: 2022-08-20
- Finding
  - Improving care quality in response to complaints or concerns
  - Published: 2022-08-20
- Finding
  - Meeting people's communication needs
  - Published: 2022-08-20
- Finding
  - Planning personalised care to ensure people have choice and control and to meet their needs and preferences
  - Published: 2022-08-20

### safe

- Finding
  - Using medicines safely
  - Published: 2022-08-20
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2022-08-20
- Finding
  - Staffing and recruitment
  - Published: 2022-08-20
- Finding
  - Learning lessons when things go wrong
  - Published: 2022-08-20
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2022-08-20

### well_led

- Finding
  - Continuous learning and improving care: Working in partnership with others
  - Published: 2022-08-20
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2022-08-20
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2022-08-20

## 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/1-9671656845

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