Background to this inspection
Updated
2 September 2020
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
The inspection team consisted of two inspectors.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in [their own houses and flats] [and] [specialist housing].
The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider would be in the office to support the inspection.
Inspection activity started on 24 June 2020 and ended on 29 June 2020. We visited the office location on 24 June 2020.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority. 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 took this into account when we inspected the service and made the judgements in this report.
We used all of this information to plan our inspection.
During the inspection
We spoke with two people who used the service and two relatives about their experience of the care provided. We spoke with two members of staff including the provider who is also the manager.
We reviewed a range of records. This included four people’s care records and medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
Updated
2 September 2020
About the service
The Potergate is a domiciliary care agency. It provides personal care to people in their own houses and flats in the community. At the time of inspection four people were receiving support.
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
Governance and performance management systems were not in place. The quality of information in care plans was limited and records we looked at did not include information about individual risks.
Medicines were not managed safely, systems were not in place to ensure people received medicines safely. The provider had not created strong systems to promote people's safety in terms of the recruitment of suitable staff. Care plans and risk assessments did not detail what care and support people needed to reduce risk to them. Most people told us they felt safe and relatives told us they thought their relatives were safe when staff visited.
People and their relatives told us staff were kind and caring and were cared for by people who knew them well. People told us staff mostly treated them with dignity and respect. People were not involved with the planning of their care, however, people said they did feel listened to.
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 12/03/2019 and this is the first inspection.
Why we inspected
The inspection was prompted in part following the emergency support framework assessment call. This is a structured framework for conversations which covers specific areas to help us monitor risk, identify where providers may need extra support to respond to emerging issues, and ensure they are delivering safe care which protects people’s human rights. Areas of concern were highlighted such as medicines, staffing and governance. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.
We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
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 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 safe care and treatment, person centred care, good governance and fit and proper person employed at this inspection.
For requirement actions of enforcement which we are able to publish at the time of the report being published: Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Special Measures:
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.