Shining Care Ltd

Updated 8 November 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 an inspector and a regulatory co-ordinator.

Service and service type

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

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 CQC 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.

Notice of inspection

We gave the service 48 hours’ notice of the inspection. This was because we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 4 October 2023 and ended on 12 October 2023. We visited the location’s office on 4 October 2023.

What we did before the inspection

Before the inspection we reviewed information we had received about the service since it registered with CQC. This included CQC notifications. These describe events that happen in the service that the provider is legally required to tell us about.

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 this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service and 4 relatives about their experience of the care provided. We received feedback from 8 professionals who worked with the service. We spoke with 10 members of staff. This included the registered manager, nominated individual, safeguarding lead and administration staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider. Everyone’s comments have been incorporated into this report.

We looked at a range of records about people's care and the running of the service. This included 5 people’s care records and a selection of medication records. We looked at 4 staff files in relation to recruitment and staff support. We read documents relating to the management of the service including audits, policies and procedures and training information.

We considered all of this information to help us to make a judgement about the service.

Updated 8 November 2023

About the service

Shining Care is a domiciliary care agency providing support and personal care to people in their own homes. The service provides support to adults who have a range of physical, cognitive, or mental health needs. At the time of the inspection, the provider told us 50 people were receiving support with personal care from the service.

Not everyone who used the service received personal care. Care Quality Commission (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

People were not always protected from the risk of abuse. Systems and processes had failed to ensure incidents of alleged abuse or harm were identified, reported, or investigated thoroughly and in a timely way.

Governance and accountability arrangements were not always clear and quality assurance systems were not effective enough to assess risk and performance and improve the quality of the service. Some audits were in place, but these were not comprehensive enough to identify and manage risks and improvements.

We received reports of a high number of missed or late visits. The people we spoke with told us staff usually arrived on time and as expected. We saw data which suggested staff were arriving for visits later than scheduled, however it also appeared the electronic recording system was not being consistently used by staff or checked by managers.

Systems to identify and address safety concerns were in place, but these were not used consistently enough to manage and reduce safety concerns, incidents and near misses.

Medicines records consistently needed to follow best practice guidance. We made a recommendation to the provider about the management of medicines.

Professionals found communication with the provider was not effective. We made a recommendation about communication to the provider. Relatives told us they were happy with the communication from staff at all levels.

People who used the service gave positive feedback in the surveys we saw. The people we spoke with were positive about the staff who supported them and the service overall.

The management team was well established and committed to providing a quality service. Staff were positive about working for the organisation and felt supported and valued in their roles.

Risk assessments were in place, up to date and regularly reviewed. 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.

We were assured that people were protected by the prevention and control of infection. Staff had access to personal protective equipment (PPE) as required, such as face masks, disposable gloves, and aprons.

The management team were keen to work with the wider community and other stakeholders to ensure people they supported were well represented and heard.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 10 June 2021).

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding, staff knowledge and skills, management oversight and standards of the service provided. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of the full 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 Shining Care Ltd on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people from the risk of abuse and ensuring management and governance arrangements are robust.

We have made recommendations relating to the safe management of medicines and effective communication with all groups.

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.