Kando Care Ltd

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of the legal requirements. Whilst people did not have any concerns around the management and running of the service, current systems to monitor and improve the quality of care provided had not always been effectively implemented. Audits had failed to identify areas of improvement in the records held for, but not limited to, accidents and incidents, medication support, people’s known risks and staff recruitment checks. As such, the quality monitoring of the service and its records did not meet the standard required. Audit action plans did not have clear information on who was responsible for the action and when the action was to be completed by. Staff were clear on their roles and responsibilities. There was a business continuity plan that included what to do in preparedness of an emergency such as climate events or staff shortages.

This service scored 7 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

During this assessment, the provider and registered manager was responsive to feedback and told us they would take action to improve the services records. The registered manager confirmed they key challenges for the service as, “Focusing on the short comings in the paperwork. (We) thought we'd wheedled out previous [named staff member] mistakes but want it to be 100%. I would like all staff to be converse in the policies.”

Whilst audits were undertaken on the service provided and records held, these audits had failed to identify all the areas that needed improvement, nor had they always completed the action required to make the necessary improvements quickly enough. We found known risks to people had not always been formally risk assessed and staffs’ daily monitoring of a person’s health condition had not been formally recorded. People and where appropriate their relatives, who had been involved in the setting up and review of their, their family members care, again had not been formally documented. There was not a complete log of all accidents and incidents that had occurred. Communications with external health professionals, again were not always formally recorded. Staff recruitment checks did not meet the standard required. As such, audits undertaken required strengthening, and scrutiny from the management team to ensure they were fit for purpose. There was a service improvement plan in place following the visit from the Cambridgeshire and Peterborough Integrated Care System in 2023. However, it was unclear as to whether the actions needed had been completed. It was also unclear as to who took responsibility to ensure the actions were completed quickly and sustained. Staff felt confident to approach the registered manager if they had any concerns. Staff told us they had supervisions and were kept up to date through regular meetings.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.