Background to this inspection
Updated
4 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
The inspection was carried out by an inspector and an Expert by Experience. An Expert by Experience is someone who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
The service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
At the time of our inspection there was a registered manager in post.
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 or registered manager would be in the office to support the inspection.
Inspection activity started on 20 August 2022 and ended on 1 September 2022. We visited the location's office on 24 August 2022.
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 took this into account when we inspected the service and made the judgements in this report. We reviewed information we had received about the service, such as details about incidents the provider must notify CQC about, for example incidents of abuse. We reviewed all other information sent to us from stakeholders such as the local authority and members of the public. We used all this information to plan our inspection.
During the inspection
We spoke with one relative about their experience of the care provided. We spoke with five staff members, including the registered manager. We looked at one care record and three staff files regarding recruitment. We also looked at quality monitoring records relating to the management of the service, such as audits and policies.
Updated
4 November 2022
Comity Hearts Care Services Ltd is a domiciliary care agency. It provides personal care to people living in their own houses and flats. At the time of our inspection, one person was receiving regulated activity. 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 the service and what we found
Robust record keeping was not in place to support the delivery of care. Staff supervisions and competency checks were not consistently recorded. Staff were up to date with training, however, there was limited oversight of training.
The person receiving care was safe and protected from the risk of abuse and avoidable harm. There were systems in place to identify lessons to be learnt. The provider held meetings with staff to share lessons learnt. However, this was not always documented.
The provider did not record late visits, however, staff told us they had enough time on visits to allow them to complete all the necessary care. There was support in place for staff. All staff received shadowing shifts and induction when they started at the service. Staff told us there was regular supervision and competency checks, however, this was not always documented.
Specific capacity assessments and best interest decisions were clearly documented. The person receiving care was given choice about how they liked their care and support to be given. Relatives told us they were supported by staff who were kind and caring. The person receiving care was asked about their desired outcomes and what they needed staff to do to support them. This meant views and opinions were understood and acted on. Staff respected dignity and privacy and promoted the persons independence. Care plans were personalised to reflect care needs. The person using the service likes, dislikes and what was important to them were recorded in their care records.
The feedback about management and leadership was positive. Staff told us they felt supported and leaders were approachable. One staff member said, "The manager is really nice, they help me with the training and stuff. They always keep in touch.”
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 6 May 2021 and this is the first inspection.
Why we inspected
This inspection was prompted by a review of the information we held about this service. 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 monitor the service and will take further action if needed.
We have identified breaches in relation to good governance at this inspection.
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 for 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.