Alcedo Care South Lakes

Updated 15 March 2024

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 2 inspectors and an Expert by Experience who made telephone calls to people who used the service and relatives. 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 and nursing 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 24 hours’ notice of the inspection. This was because we wanted to be sure there would be management staff available to speak with us.

Inspection activity started on 5 December 2023 and ended on 8 December 2023. We visited the location’s office on 5 December 2023 and 6 December 2023.

What we did before inspection

We reviewed information we had received about the service since registering with us. We sought feedback from the local authority and professionals who work with the service. 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 with 1 person who used the service and 10 relatives about their experience of the care provided. We spoke with 10 members of staff including the registered manager, the company’s compliance manager, a training manager, care manager, care coordinator, and care workers. We reviewed a range of records. This included 5 people’s care records and medication records. We looked at 5 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 15 March 2024

About the service

Alcedo Care South Lakes is a domiciliary care service, providing personal care and treatment of disease, disorder or injury to people living in their own homes. The service is managed from the registered office in Kendal and services are provided to people living in the South Lakes area. At the time of this inspection 19 people were receiving the regulated activities. 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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

At the time of this inspection, the location did not care for anyone with a learning disability or for an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

Right Support:

Although people felt safe, some aspects of the safety of the service needed to be improved.

Safeguarding incidents were identified and shared with the local authority. However, not all of the incidents and allegations had been notified to us, as legally required.

Most risks relating to people's needs had been identified. However, some care records did not provide a detailed plan for managing the risks associated with some of the equipment people required such as bed rails and wheelchairs. Immediate action was taken by the registered manager during the inspection to rectify this. Systems were in place to record accidents and incidents. These were consistently monitored to identify any lessons learned, themes or trends.

Medicines were not always managed safely, and medicine audits were not always effective, for example, a topical medicine was out of date and had continued to be used by care staff. All staff told us they had been trained in the management of medicines and had been observed for competency when giving them. There were enough staff to adequately support the number of people using the service. Recruitment checks of suitability had been carried out by the provider.

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. Consent to care and treatment had been obtained and where people lacked capacity relevant others had been involved in supporting people's decision making.

Right Care:

People received kind and compassionate care from staff who knew them well. People told us staff treated them with respect and dignity and were very caring towards them. Care plans demonstrated a person-centred approach. Records showed complaints were processed and responded to. End of life care where relevant was done co-working with the community nurses.

Training records demonstrated appropriate and relevant training was provided. Referrals were made to other healthcare services when necessary. People told us they thought the care they received was good and spoke very positively about the staff who supported them.

Right culture:

Quality monitoring and auditing systems were not always effective. A variety of regular audits had been undertaken. However, these were not always effective in highlighting the concerns we found with notifying us about of allegations of abuse, records for managing the risks associated with equipment and the safe management of medicines. This could put people at risk of not receiving safe and good quality care.

Electronic care planning and rota systems were used. People could access the electronic care planning system remotely to view information about their or their relative’s care. People’s views of their experience of the service were regularly gathered. People provided us with positive feedback about how the service was managed, the registered manager and care staff.

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 15 November 2022, and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Recommendations and breaches

We have identified a breach in relation to good governance and the systems and processes used for monitoring the oversight of the quality and safety of the service.

The provider and registered manager responded immediately during and after the inspection to address the completion of records about risks and improve the quality of the systems used for the monitoring the service in order to mitigate any further risks.

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.