Background to this inspection
Updated
2 December 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 Health and Social Care Act 2008.
Inspection team
The inspection team consisted of 2 inspectors and an Expert by Experience. 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 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
The inspection was announced. We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure the provider or registered manager would be in the office to support the inspection.
What we did before the inspection
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 reviewed all the information we held about the service including information about important events which the service is required to tell us about by law. We requested and received feedback from other stakeholders in Leeds and York. These included the local authority safeguarding team, Healthwatch, and commissioners. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.
During the inspection
We spoke with 7 people who were using the service, 1 carer, and 2 relatives of people using the service. We spoke with 10 support workers, the office administrator, and the registered manager. We looked at care records for 3 people. This included medication administration records, risk assessments, care plans, and daily records. We reviewed staff recruitment files, various policies and procedures, and the quality assurance and monitoring systems of the service.
Updated
2 December 2023
About the service
Number 12 Chapeltown Enterprise Centre is a domiciliary care agency providing personal care. The service provides support to adults living in their own homes. At the time of our inspection there were 40 people using the service.
People’s experience of the service and what we found:
We found the provider did not always follow safe recruitment processes, carry out decision specific mental capacity assessments, or record details of 'when required' medications in care plans. We made recommendations in these areas. We found people who used the service were happy with their care. The provider care plans were person centred and detailed.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. At the time of the inspection, the location did not care or support for anyone with a learning disability or 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
The staff supported people to have the maximum possible choice, control, and independence. Staff spoke confidently about always offering people choice. One person told us, “They [carer staff] are all very good to me and are always asking permission.”
Right Care
People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs. People told us, “They {care staff] have shown so much care and compassion, it’s been unreal.”
Right Culture
People received good quality care, support and treatment because trained staff and specialists could meet their needs and wishes. A staff member told us the team “Is like a family” and one person told us, “I can rely on them.”
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.
We have made recommendations about recording information of ‘when required’ medication in care plans, safe recruitment processes, and completing capacity assessments in line with current guidance and legislation.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good published 13 June 2019.
Why we inspected
The inspection was prompted in part due to concerns received about staff competencies, Disclosure and Barring Service (DBS) checks, and medication administration. A decision was made for us to inspect and examine those risks.
We undertook a focused inspection to review the key questions of safe and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Number 12 Chapeltown Enterprise Centre on our website at www.cqc.org.uk.
Follow Up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.