Background to this inspection
Updated
8 February 2022
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 conducted by one inspector 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 homes in the community. The service had a manager who was registered with the Care Quality Commission. This means that they, and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was announced. We gave the service 48 hours' notice of the inspection. This was because we needed to be sure that the provider or the registered manager would be in the office to support the inspection. The inspection activity commenced on 13 January 2022 and ended on 14 January 2022.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We also looked at notifications received from the provider. A notification is information about important events which the provider is required to tell us about by law. This ensured we were addressing any areas of concern.
During the inspection
We spoke with one person and six relatives. We looked at four people's care records and four medicine administration records (MAR). We spoke with one carer, the care manager, the marketing manager and the registered manager. We reviewed a range of records relating to the management of the service. These included medicine records, quality assurance audits, training records, policies and surveys. In addition, we contacted the local authority commissioning team and reviewed records they had sent to us.
Updated
8 February 2022
Siete Care Services is a domiciliary care agency (DCA). The service provides personal care services to people in their own homes.
At the time of our inspection nine people received personal care as the regulated activity. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is to 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
The registered manager had quality assurance systems in place to monitor the quality and safety of the service. These systems were used to improve the service. The service had a clear management and staffing structure in place and promoted a positive, caring culture.
Medicines were administered safely. Medicine records were accurate and up to date. Staff's competency to safely administer medicine was regularly checked and recorded.
People told us they felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and they felt confident in how to report these types of concerns. People had risk assessments in place to enable them to be as independent as they could be in a safe manner.
There were sufficient staff on duty to support people with their needs and keep them safe. Effective and safe recruitment processes were followed by the provider. However, we were told recruitment was “difficult at this time” and staff and managers were working extra hours to provide and maintain the service.
People were safe from the risk of infection. This included measures introduced by the provider to safeguard people and staff from COVID-19.
This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection.
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 Requires Improvement (Report published 6 November 2020). There was one breach of Regulation 17 HSCA RA Regulations 2014 Good governance. Systems to monitor the service did not identify our concerns relating to records.
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection found improvements had been made and the provider was no longer in breach of regulations
The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
Why we inspected:
This was a planned inspection based on the previous rating.
Follow up:
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.