# Xen Care Services

*Operated by Support Haven Ltd.*

Xen Care Services is a CQC-regulated home-care agency in Ipswich.

## CQC Ratings

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

Rating published: 13/04/2022

## Practical info

- Postcode: IP2 0UG
- Local authority: Suffolk
- Region: East
- City: Ipswich
- Last CQC check: 07/Sep/2023 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Provider proactively sought support from the local authority commissioning team following inspection feedback.
  - Published: 2023-09-16
- Finding
  - Evidence: Management team were described as approachable and supportive by staff.
  - Published: 2023-09-16
- Finding
  - Evidence: Mental capacity assessments were carried out and documented in care plans where required.
  - Published: 2023-09-16
- Finding
  - Evidence: People reported feeling safe and were complimentary about the approach of care staff.
  - Published: 2023-09-16
- Finding
  - Evidence: No missed care calls were evidenced and staff had sufficient travel time between visits.
  - Published: 2023-09-16
- Finding
  - Evidence: Staff received infection prevention and control training and were provided with adequate PPE.
  - Published: 2023-09-16
- Finding
  - Evidence: Staff received training relevant to their role including Oliver McGowan Mandatory Training on Learning Disability and Autism.
  - Published: 2023-09-16
- Finding
  - Evidence: Medicines were managed safely with monitoring of administration records and processes to identify and address errors.
  - Published: 2023-09-16
- Finding
  - Evidence: Staff were safely recruited with all relevant pre-employment checks completed including DBS checks.
  - Published: 2023-09-16
- Finding
  - Evidence: Risk assessments had recently been reviewed and amended, and measures were put in place to guide staff on how to reduce risks.
  - Published: 2023-09-16
- **person_centred_care** _(moderate)_
  - Evidence: The provider did not have due regard to 'right support, right care right culture', despite being registered as a specialist service for people with a learning disability and autistic people.
  - Published: 2023-09-16
- **supervision_appraisal** _(minor)_
  - Evidence: There had been slippage with formal supervisions but the management team had identified this and supervisions were planned.
  - Published: 2023-09-16
- **safeguarding** _(moderate)_
  - Evidence: Not all were confident in the processes for escalating concerns to relevant stakeholders externally.
  - Published: 2023-09-16
- **complaints_handling** _(minor)_
  - Evidence: The provider's complaints policy and procedure needed updating to ensure information on how complaints were managed was correct to manage people's expectations.
  - Published: 2023-09-16
- **leadership** _(critical)_
  - Evidence: The service did not have a manager registered with the Care Quality Commission. The management team were new and had been in post for 6 weeks.
  - Published: 2023-09-16
- **care_planning** _(moderate)_
  - Evidence: Care plans and risk assessments had been updated and were accurate, they lacked detail in certain areas and were often generic.
  - Published: 2023-09-16
- **incident_learning** _(moderate)_
  - Evidence: There was not a robust system in place for the provider to evidence how they learned lessons when things go wrong and to reduce the risk of reoccurrence.
  - Published: 2023-09-16
- **governance** _(critical)_
  - Evidence: The provider did not have robust processes in place to monitor the safety and quality of the service. This demonstrated a continued breach of regulation 17 (Good governance)
  - Published: 2023-09-16

### safe

- Finding
  - Preventing and controlling infection
  - Published: 2023-09-16
- Finding
  - Using medicines safely
  - Published: 2023-09-16
- Finding
  - Staffing and recruitment
  - Published: 2023-09-16
- Finding
  - Systems and processes to safeguard people from the risk of abuse
  - Published: 2023-09-16
- Finding
  - Learning lessons when things go wrong
  - Published: 2023-09-16
- Finding
  - Assessing risk, safety monitoring and management
  - Published: 2023-09-16

### well_led

- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2023-09-16
- Finding
  - Continuous learning and improving care
  - Published: 2023-09-16
- Finding
  - Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements
  - Published: 2023-09-16
- Finding
  - Engaging and involving people, public and staff; working in partnership with others
  - Published: 2022-04-13
- Finding
  - Promoting a positive culture and acting on the duty of candour
  - Published: 2022-04-13
- Finding
  - Managers and staff being clear about their roles; understanding quality, risks and regulatory requirements
  - Published: 2022-04-13

## 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/1-9983501615

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