Moonlight Homecare 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

Staff felt supported by the provider and were able to raise any questions or concerns they may have. However, we found a breach of the legal regulation in relation to good governance. The provider did not always ensure care plans contained information on the care a person required and identified their wishes as to how it should be provided. The risk assessment contained information which did not always relate to the person. The provider’s quality assurance processes for reviewing care plans and risk assessments, did not enable them to identify where information was not provided or was not accurate. We have asked the provider for an action plan in response to our concerns.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Care workers told us they felt there was a good culture within the organisation and that it was well led. Comments included, “I think it's fair and everyone is nice. We all work together to help people” and “Yes, I think the people in charge know what they're doing, and they care about us and the people we support.”

The provider had a range of procedures and policies in place which provided staff with guidance on best practice and regulations. Records showed staff followed these to provide care safely.

Care workers told us they felt supported by the provider. A care worker commented, “Yes, my manager is always there to help me when I need it.” The provider did not demonstrate an understanding that there were issues with the information management of the service.

The provider communicated with care workers, people receiving support and their relatives or friends to get feedback on the care being provided and how the service was being run. They used the feedback to make improvements when needed.

Care workers told us they felt the provider was approachable and they were able to raise issues with them. A care worker told us, “Yes, I feel supported by my manager, who is approachable and available to provide guidance and assistance whenever needed.”

The provider has a whistleblowing policy and told us, “We encourage [care workers] to speak up in line with the whistleblowing policy. We explain to them how important safeguarding is and it is everyone’s responsibility to report any safeguarding [concerns] and if anything is disclosed to tell us or local authority.”

The provider told us their care workers spoke the preferred languages of the people they were supporting. They also reflected the languages spoken in the local community. There were also male and female care workers so that the personal preference of people being supported could be met.

Care workers had completed training in relation to effective communication and equality, diversity and inclusion which provided them with the skills to support people to meet their cultural and religious preferences.

The provider confirmed they had developed a business contingency plan and workforce planning document. There was also a cyber security and data security and protection toolkit in place. The provider had also created a leadership development program which was designed to ensure managers and supervisors had the skills and knowledge to drive improvement. Although the provider had systems in place, they had not taken action on the recommendations made following the inspection in May 2023 relating to ensuring care plans were accurate, contemporaneous and complete.

Care plans has been developed for each person, but these did not always reflect what the person’s support needs were and how they wanted the care provided. The care plans did not include information on the support people required with their personal care including incontinence and how care workers could provide this. The guidance in the care plan, on how care workers should support a person relating to continence care, stated that care workers should let them know when they are finished and make sure the front door is shut. There was no information how the person wanted their support to be provided. The information provided in people’s risk assessments did not always relate to them. The risk assessments for 2 people stated they had allergies to penicillin, but the provider confirmed they did not have this allergy. The falls risk assessments for each person stated they were living with a visual impairment, but the provider confirmed this was not accurate for any of the 3 people being supported. Failure to ensure records provided up to date information and reflected people’s care needs and preferences was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider told us they were in contact with the local authority when needed in relation to the funding of a care package and they supported people to access their GP if they required assistance.

The provider carried out reviews of care plans and risk assessments annually or if there was a change in the person’s support needs. They also carried out 2 spot checks of visits per year. The provider also informed us that they planned to undertake monthly telephone quality assurance calls to people receiving support and this had not always taken place. Feedback from people receiving support from the records of the telephone interviews provided was positive and stated they were happy with their care.

The provider had quality assurance processes in place. However, these were not used effectively to identify issues in relation to guidance and information provided to care workers on how people wanted their care provided. The care plan reviews did not identify that there was a lack of information on the person’s preferences on how their care should be provided. Records were not well maintained. Reviews of the risk assessments failed to identify that some of the information recorded was not accurate and did not relate to the person being supported. Records for the monthly monitoring calls to people using the service were not consistently kept. This meant the provider could not take actions which were required to make improvements. Failure to effectively operate systems and processes to assess and monitor and improve the quality of the service was a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.