Background to this inspection
Updated
26 November 2022
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
This inspection was carried by two inspectors and an Expert by Experience.
An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service
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.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.
Inspection activity started on 26 September 2022 and ended on 29 September 2022. We visited the location’s office/service on 26 September 2022.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. 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 all this information to plan our inspection.
During the inspection
We spoke to a representative of the provider, the registered manager and the recruitment manager. We spoke by phone to one senior carer and three care staff. We reviewed a range of care documentation and medicines records. We also spoke by phone to five people who use the service and three relatives of people who use the service. We looked at three staff files in relation to recruitment and staff development and support. A variety of records relating to the management of the service, including policies and procedures and staff training and quality assurance records.
Updated
26 November 2022
About the service
Five Valley Care LTD is a domiciliary care service providing personal care for people in their own home. At the time of the inspection, fifteen people were receiving support from the service with personal care.
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
Improvements were needed to ensure safe recruitment practices were followed. The provider’s audits were not fully effective in identifying and addressing quality and safety concerns in areas of staff recruitment.
People's individual risks were assessed and staff were given information on how to protect people from the risks associated with their care. However, the care documentation related to the risk management of people’s health needs was not always comprehensive. We have made recommendations about risk management plans related to people’s health needs and the quality assurance systems related to this area.
We did not find that these shortfalls had impacted on people's care.
The provider responded to our inspection feedback and was open to making improvements to the service. The provider began reviewing people's care documentation and their quality assurance systems during the inspection.
People who used the service and their relatives were positive about the caring nature of staff and managers and told us they felt safe.
Care staff had the training and experience they needed to meet people's needs.
People received care and support from a consistent staffing team. Staff spoke positively about the support they received and how this promoted person centred care.
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.
Systems were in place for people to raise concerns and for the registered manager to receive feedback from people who used the service. This enabled them to monitor the quality of the service being provided to people.
Rating at last inspection
This service was registered with us in April 2021 and this is the first inspection.
Why we inspected
This service had not been inspected since their registration; therefore, this inspection was carried out to gain assurances about the quality of care and systems used to monitor and manage the service.
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 a breach in relation to safe recruitment practices.
We have made recommendations about risk management plans related to people’s health needs and the quality assurance systems.
You can see what action we have asked the provider to take at the end of this full 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.