16 September 2022
During a routine inspection
Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.
People’s experience of using this service and what we found
Staff did not always have access to clear and detailed risk management and medicines care plans to help guide them in their role when supporting people with specific and individual needs.
Safe recruitment practices were not always followed to ensure people were supported by suitable and vetted staff. Progress was being made in the development, support and training of staff. The provider had plans in place to help further support staff with their training and knowledge of current health and social care practices.
Systems were in place to safeguard people from abuse and the spread of infection. All incidents, concerns or complaints were recorded and investigated by the management team to help resolve any concerns or prevent reoccurrence. However, some significant incidents had not been notified to CQC in line with their registration requirements.
The quality monitoring systems implemented by the provider to help them monitor the quality of the service had not always been effective in identifying and addressing gaps in the service such as shortfalls in their recruitment practices.
People’s care, risk and medicines records did not fully reflect their needs and how staff should support them. However, the provider had recently implemented a new management team who were in the process of appraising the service. They shared with us their initial findings and their action plan to address gaps in the service and make improvements. However further time was needed to demonstrate their findings and actions had been effective and would be maintained to ensure people received safe and effective care.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff worked with people, their relatives and other key professionals to help them maintain a healthy and safe life living in their own home.
People’s cultural and diverse needs were recognised and supported. Where needed, adjustment had been made to help reduce barriers in communications and to support people with their cultural, dietary needs and preferred choices of food and drinks.
People and their relatives reported they received personalised and good quality of care from staff who were kind and compassionate. Systems were in place to manage and monitor the punctuality of staff’s care calls. Staff reported the culture of the service was open and positive.
At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 3 August 2022 and this is the first inspection.
Why we inspected
This service had not been inspected since their registration; therefore, this inspection was carried out to gain assurances about the quality of care and systems used to monitor and manage the service.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to safe recruitment, safe care and treatment of people, and the governance of the service at this inspection and notifying CQC of significant events.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.