Luna 3-6-5 Healthcare Services Ltd

Updated 7 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by one inspector.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post who is also the provider.

Notice of inspection

We initially gave the service 24 hours’ notice of the inspection. This was because we needed to be sure that the provider/registered manager would be in the office to support the inspection. Due to the providers availability, the inspection started two and a half weeks after notice of the inspection was given.

What we did before the inspection

We reviewed information we had received about the service since registration. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 28 September 2022. We used all this information to help plan the inspection and inform our judgements.

During the inspection

Inspection activity started on 24 November and ended on 5 December 2022 at 5pm. We visited the location's office on 24 and 30 November 2022. We spoke with three people, three relatives of people using the service, one staff and the registered manager who is also the provider.

We reviewed a range of records. We looked at one staff file in relation to recruitment. We looked at five people's care plan records. We reviewed a range of policies, training data and quality assurance records.

Updated 7 March 2023

About the service

Luna 3-6-5 Healthcare Services Ltd is a domiciliary care agency providing personal care and support to people living in their own homes. 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. At the time of the inspection five people were receiving personal care from the service.

People’s experience of using this service and what we found.

Not all risk in relation to people receiving personal care was assessed. People had care plans in place, however, these did not include clear information to guide staff to provide care and support.

People were at risk of harm due to poor medicines management. There was a lack of information to ensure staff understood when to give medicines which were prescribed 'as and when required'.

Safeguarding and infection control procedures had not always been operated effectively and the provider was not working in line with the principles of the Mental Capacity Act 2005.

Systems and processes for care call monitoring were not effective. One person raised a concern regarding late calls.

Improvements were needed to ensure staff were safely recruited, had a programme of induction and training, and to ensure staff received ongoing support and guidance through supervision and the assessment of their competence to fulfil their role.

The provider had not operated effective systems and processes to assess, monitor and improve the quality and safety of the services. The provider's audits was not always effective.

We discussed these concerns with the provider/registered manager who was responsive to feedback and started making changes to improve the service. A consultant was being used to support these changes.

People’s care needs were assessed before their care package started. People and relatives were involved in this.

People were well treated and supported. Staff knew people and their needs and preferences well and people received consistent care. Staff respected and promoted people's privacy and dignity and supported them to be as independent as possible. People and relatives told us staff were kind and caring.

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 23 November 2022 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Enforcement and Recommendations

We have identified breaches in relation to recruitment, medicines management, risk management, safeguarding, assessment and care planning, staffing and the management of the service.

We have also made recommendations in relation to the Mental Capacity Act.

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 to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.