26 July 2022
During a routine inspection
People’s experience of using this service and what we found
Staff recruitment checks had not been fully robust. Not all expected checks on staff’s employment history and references had been completed. Action was being taken by the provider to address this.
The provider's governance systems and procedures in how quality and safety were assessed, monitored, and managed found inconsistencies. Improvements were required with staff support. Audits and checks had not been consistently completed at regular intervals the provider had identified as required. Guidance for staff about how to meet people's individual care needs found some information was insufficiently detailed or contradictory.
People and relatives spoke positively about their experience of the service. Staff provided consistent care that was largely provided on time and staff were unrushed. Staff were described as caring, compassionate and provided safe care that was dignified and respectful.
Local authority commissioners reported the provider was working with them to make improvements, further time was required for these to become fully embedded and sustained. The provider had an action plan and was developing their management team to support the service to drive improvements.
Improvements were being made to staff training. Incidents, accidents and complaints were investigated. Action was taken to learn and make improvements and risks mitigated.
People were involved in their assessment, development and ongoing reviews of their care. The management team completed spot checks, monthly welfare calls and invited people to complete feedback surveys to share their experience.
People were provided with support with their dietary needs and to keep hydrated. 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
This service was registered with us on 3 November 2021 and changed office address on 6 July 2022 and this is the first inspection.
Why we inspected
The inspection was prompted in part due to concerns received about staff behaviour. A decision was made for us to inspect and examine those risks.
Where we found some shortfalls, the provider was taking some action to make improvements.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective 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.
We have identified one breach in relation to governance 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 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.