Background to this inspection
Updated
23 February 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 31 January 2018 and 1 February 2018 and was announced. We gave the service 48 hours’ notice of the inspection visit because the manager is often out of the office supporting staff or providing care. We needed to be sure that they would be in.
In preparation for our visit, we checked the information we held about the service and the provider. This included complaints, safeguarding information and statutory notifications sent to us by the registered provider about incidents and events that had occurred at the service. A notification is information about important events, which the service is required to send us by law. We contacted the local authority monitoring team and received positive feedback about the service. We also received feedback from Healthwatch UK.
We used information the provider sent us in the Provider Information Return (PIR). This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.
We visited the office location to meet with the nominated individual, the managers and office based staff and to review care records and policies and procedures. We reviewed a range of records about people’s care and the way the service was managed. These included the support plans and associated records for four people, three staff recruitment files, staff training, supervision and appraisal records, minutes from meetings, quality assurance systems, incident and accident reports, complaints and compliments records and records relating to the management of the service. We also looked at the results from the provider’s recent customer satisfaction survey and at the most recent report from the local authority monitoring team.
Following the visit to the agency office we spoke with four people using the service, two relatives and five care staff over the telephone. Following the inspection we asked the provider to send us some additional information; this was done promptly.
Updated
23 February 2018
This inspection took place on 31 January 2018 and 1 February 2018 and was announced.
During our previous inspection on 27 and 28 July 2016, we found concerns relating to the recruitment of staff, the management of people’s complaints and lack of effective systems to monitor and develop the service. At that time we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Effective, Responsive and Well Led to at least good.
During this inspection visit we found the necessary improvements had been made.
Majestic Care North West Limited is a domiciliary care agency. The service provides personal care and support to people living in their own homes in the Burnley and Pendle area. The range of services provided includes personal care, domestic support, meal preparation and shopping. The agency office is located in the centre of Burnley.
People’s care and housing are provided under separate contractual agreements. The Care Quality Commission (CQC) does not regulate premises used for people supported in their own homes; this inspection looked at people’s personal care and support. At the time of the visit there were 89 people who used the service.
We gave the service 48 hours’ notice of the inspection visit because it is domiciliary care service and the manager is often out of the office supporting staff or providing care. We needed to be sure that they would be in.
At the time of the inspection, the service did not have a registered manager. Two new managers had been employed from December 2017 and an application to register them with CQC had been forwarded. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People told us they felt safe and staff were caring and treated them well. They told us staff were like their family and they trusted them implicitly. People said they received care and support from a consistent team of staff with whom they were familiar. They told us staff mainly arrived on time and stayed for the full time allocated. People spoke positively about the staff that supported them and told us they were always treated with care, respect and kindness. Staff had developed good relationships with people and were familiar with their needs, routines and preferences. The management team told us additional work was underway to ensure everyone was provided with a consistent team of staff.
Safeguarding procedures were in place and staff understood their responsibilities to safeguard people from abuse. Potential risks to people's safety and wellbeing had been assessed and managed; further improvements were needed. People told us they received their medicines safely; there were systems in place to monitor safe practice in this area. The recruitment process had improved and additional improvements were made during the inspection to ensure a safe process.
Staff had sufficient knowledge and skills to meet people's needs effectively. New staff completed an induction programme and all staff were provided with regular mandatory training, supervision and support. Staff felt they were supported by the management team and told us they enjoyed working for the agency.
People were involved in the development of their support plans and involved in any discussions and decisions about their care. Staff had clear and up to date information about people’s needs and wishes and there were systems in place to respond when their needs changed.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.
People were supported with their healthcare needs as appropriate and supported with their dietary needs in line with their support plan. Staff supported people to access the local community and to pursue their leisure interests in line with their support plan.
People spoken with had no complaints about the service they received or about the staff that provided their care and support; they were aware of the complaints procedure and processes and were confident they would be listened to should they raise any concerns.
People made positive comments about the leadership and management of the agency. Systems to monitor the quality of the service had been improved and people’s feedback was sought and acted upon in relation to the standard of care and support.