Ave Maria Care (Wolverhampton)

Ave Maria Care Wolverhampton is a domiciliary care agency providing personal care to people living in their own homes. The service provides support to older people, younger people, and people with dementia. There were 23 people using the service at the time of our 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

Systems were developed and put in place in response to the concerns raised during the last inspection. These included concerns over safeguarding, care planning and governance. Improvements were made to the quality auditing processes and safe care and treatment. The provider also introduced specialist staff training to support people with specific conditions and they reviewed their auditing and governance systems to have a clearer oversight of the service provided.

The provider employed a new administer to support them with the monitoring and auditing processes and they developed a new senior carer role to assist with the oversight of people’s care and staff. The registered manager was keen to develop a culture of improvement, partnership working and transparency.

The provider monitored the quality of care and support provided to people. The provider completed regular audits of the care plans, risk assessments and medicine administration. Improvement was identified and acted upon in a timely manner.

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

Rating at last inspection and update

The last rating for this service was requires improvement (Published 4 February 2023).

At our last inspection we found breaches of the regulations in relation to safe care and treatment, safeguarding and good governance, which meant there was a lack oversight of risk within the service to keep people safe. The provider was made aware of our concerns and the improvements which were required to be completed by 31 December 2022.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulations 12, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ave Maria Wolverhampton on our website at www.cqc.org.uk

Follow up

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

Ave Maria Care Wolverhampton is a domiciliary care agency providing personal care to people living in their own homes. There were 15 people using the service at the time of our 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

People’s care plans and risk assessments did not always identify how to support them with their individual needs. Staff had not always receive training which reflected people’s needs to ensure they could support people in a safe way. We were not always assured people received prescribed medicines safely . Care plans did not identify side effects of medication which meant people were at increased risk of harm. People and relatives told us they were concerned about care call times being changed without them being made aware. Some people received their time specific medicines appropriately.

The provider’s safeguarding procedures did not ensure people were protected from abuse. Governance systems were not effective and had not enabled the provider to identify concerns about the safety and quality of people’s care. The provider’s audits had not identified concerns we found during our inspection including concerns with medicines, safeguarding and call times.

Precautions were in place to protect people from the risk of infections. However, some people told us staff did not wear personal protective equipment (PPE) consistently. We have made a recommendation about the effective use of PPE.

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's suitability to work with people in their homes was checked before they started employment. People were happy with the staff who supported them and found them to be caring. People's privacy and dignity was considered and maintained. People were encouraged to make choices and remain independent. Peoples' communication needs were considered. There was a complaint policy in place, which was followed when needed.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 April 2022) and there were breaches of regulation.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulation 12, (Safe care and treatment) regulation 13 (Safeguarding service users from abuse and improper treatment) and regulation 17 (Good governance).

At our last inspection we recommended that the provider reviewed current guidance on the assessment and management of associated COVID-19 risks and took action to update their practice. At this inspection we found the provider had acted on some recommendations and had made improvements.

Why we inspected

We received concerns in relation to staffing levels and missed/ altered calls. 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. You can see what action we have asked the provider to take at the end of this full report.

The provider had already started to address issues with care plans at the time of the inspection to reduce risk to people.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ave Maria (Wolverhampton) on our website at www.cqc.org.uk.

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 managing people’s risks, administering medicines and governance and oversight of the service at this inspection.

Please see the action we have told the provider to take at the end of this report

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ave Maria Care (Wolverhampton) is a domiciliary care service providing personal care and support to people in their own homes. They were providing a service to 64 people at the time of inspection; all of whom were receiving 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

We found significant concerns about the management of the service. Their systems were not effective to assess, monitor and improve the quality and safety of the service. Their systems had failed to ensure risks were properly assessed, documented and mitigated. Staff worked in a negative workplace culture and appropriate action was not taken to improve this.

People’s risks of avoidable harm were not always identified to ensure action was taken. Medicine was not always administered safely or effectively. There were not enough staff to ensure people’s care was provided consistently and safely. People were not always protected from the risk of abuse. Staff followed infection control practices, however individual risks to people’s health from Covid-19 were not assessed.

Staff understood people’s needs and how to access additional support for people when needed. Some people felt their concerns were not always listened to by the management team while other people felt listened to. People with communication needs were supported to express themselves through alternative methods. Staff supported people’s well-being when they felt isolated.

Staff received training appropriate to their roles and their competencies were checked. People were supported to eat and drink, however this was not always consistent for some people. Care plans were completed that identified people's needs and provided guidance to staff in providing safe care. People were supported to make choices and decisions and staff promoted their independence.

People were not always supported to express their protected characteristics for personalised care to be put in place. People felt supported and cared for and staff spoke fondly of the people they supported. Care staff treated people with respect and compassion and ensured people’s dignity was maintained.

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.

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 14 January 2021 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels at the service. 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 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 managing risks to people's safety; staffing; governance and oversight of the service at this inspection.

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.