Background to this inspection
Updated
20 March 2021
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 Care Act 2014.
Inspection team
There was one inspector in the inspection team.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 21 December 2020 and ended on 21 January 2021. We visited the office location on 21 December 2020. Due to the restrictions of COVID-19, we reviewed most records electronically off site and visited the office for a short period of time to check the provider’s system for reviewing care.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We did consult the local authority and sought feedback from them. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with three people who used the service and two relatives about their experience of the care provided. We spoke with six members of staff including the registered manager, assistant manager and senior care workers.
We reviewed a range of records relating to the management of the service, including policies and procedures.
After the inspection
We continued to seek clarification from the provider to understand why there was a discrepancy in the registration records we held for them.
Updated
20 March 2021
About the service
This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats. 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 17 people received support with their care.
People’s experience of using this service and what we found
The registered provider did not have effective systems for governance. The registered provider relied on the administrative staff to make them aware of issues when they were working off site (in order to comply with the Government’s COVID guidance). However, the registered manager was not made aware of issues that arisen that required their attention. The registered provider had also moved office and failed to update their registration.
People were positive about the staff supporting them and felt staff had the required knowledge to support them.
People received their medicines from staff who had received training to support people safely.
People and staff felt supported by the registered manager when they were available. However, systems were not always robust when the registered manager was not available. When the registered manager was made aware of the issues they immediately took action to make people’s experience of care safe.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Why we inspected
The inspection was prompted in part due to concerns received about people having experienced missed calls. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the Safe and Well led sections of this report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Beavers (Worcester) Limited on our website at www.cqc.org.uk.
Enforcement
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 to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to registration requirements as well as how the registered provider monitors people experience of care.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will monitor the service moving forwards seeking an action plan to explain how they will make improvements.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.