IMG-Surrey

Updated 9 February 2023

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 Care Act 2014.

Inspection team

The inspection was carried out by 1 inspector.

Service and service type

Siddeley House is a domiciliary care agency, registered for 'personal care'. The service provides personal care to older people who may be living with dementia, have a physical disability, sensory impairment and younger adults.

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 needed to be sure that the provider or registered manager would be in the office to support the inspection. Inspection activity started on 8 January and ended on 25 January 2023. The inspection visit took place on 10 January 2023.

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 and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke in person with the registered manager. We spoke with 10 people using the service and their relatives, 8 staff and 3 health care professionals who have regular contact with the service, to get their views about the care provided. We looked at 5 people’s care plans and 2 staff records. We reviewed a range of records. They included staff rotas, training and supervision, risk assessments, reviews and a variety of records relating to the management of the service, including audits, quality assurance, policies and procedures. We continued to seek clarification from the provider to validate evidence found. We requested additional evidence to be sent to us after our inspection. This included spot checks, observations, training matrix and audits. We received the information which was used as part of our inspection.

Updated 9 February 2023

About the service

Siddeley House is a domiciliary care agency. It provides support and personal care to people living in their own houses and flats.

The Care Quality Commission (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. At the time of the inspection 44 people using the service were receiving personal care.

People’s experience of using this service and what we found

At the last inspection the service provided was not always safe for people to use as people’s support visits were not always occurring at the agreed time or lasting for the agreed duration. The care provided was not always effective as some people and their relatives thought the difference in the quality of skill sets of individual staff members, showed a need for training more focussed on the needs of individual staff. The service was not always well-led as the quality assurance system did not always identify and address people's concerns about the service delivered.

At this inspection people and their relatives said that calls were taking place on time and lasting for the agreed duration. People were informed if staff were running late. There were enough staff who were appropriately trained and provided care and support in a friendly way. The quality assurance system identified and addressed people's concerns about the service.

People received a safe service with risks to people assessed, monitored and reviewed. This enabled the provider and staff to minimise risks to people. There were enough appropriately recruited staff. Accidents, incidents and safeguarding concerns were reported, investigated and recorded. Medicines were safely administered by trained staff. Personal Protective Equipment (PPE) was available and current guidance followed. The infection prevention and control policy was up to date.

The service was effective with peoples’ needs assessed, and they were given choices, as to when and how they would receive care and support. Staff encouraged them to discuss their health needs, any changes to them and they were passed on to appropriate community-based health care professionals. Staff received appropriate, good quality training. The provider was part of a professional’s network promoting joined up working between services based on people’s needs, wishes and best interests. This included any required transitioning of services if people’s needs changed. Staff protected people from nutrition and hydration risks, and they were encouraged to choose healthy and balanced diets that also met their likes, dislikes and preferences.

The service was well-led with quality regularly reviewed, and changes made to improve the care and support people received. The provider had a culture that was positive and open, with an identifiable leadership and management structure. The provider’s vision and values were clearly set out, staff understood them and were aware of their responsibilities and accountability. The provider established working partnerships to promote the needs of people being met outside its remit to reduce social isolation. Registration requirements were met.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 16 September 2022) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contained those requirements and a recommendation. A decision was made for us to inspect and examine the risks associated with these issues.

CQC has introduced focused inspections to follow up on previous breaches and to check specific concerns.

As no concerns were identified in relation to the key questions Caring and Responsive, we decided not to inspect these questions. Ratings from the previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Siddeley House on our website at www.cqc.org.uk.