Bilborough

Updated 5 October 2019

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 team consisted of one inspector

Service and service type; Notice of inspection

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats. The service had a manager 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. This inspection was announced. We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

This service was registered with us on 10 October 2018 and this is the first inspection. Inspection activity started on 20 May 2019 and ended on 22 May 2019. We visited the office location on 20 and 22 May 2019.

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 used all this information to plan our inspection.

During the inspection

During the inspection we spoke with one person who used the service and the registered manager. The registered manager was also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included one person’s care and medication administration records [MAR]. We looked at four 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 5 October 2019

About the service

Bilborough is a domiciliary care service providing personal care to people in their own homes. The service was supporting one person at the time of the inspection.

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

We found staff recruitment checks were not always carried out and there were no records of staff interviews. Some policies and procedures were not suitable for the service and not understood by staff. Risk assessments for tissue viability and health conditions were not clear, did not contain necessary information and were not signed and dated. Topical creams were not recorded consistently, so we could not be sure they had been applied as prescribed. We could not be sure daily records were always completed, three months’ worth of daily records could not be viewed because they were in storage. On the records available to us staff handwriting did not always match their previous entries. This meant we could not be sure who had recorded the information.

Needs assessments, care plans and reviews lacked information, some were generic, and most were not signed and dated. The service did not always promote an open culture where lessons were learnt, and improvements were made. Audits for cream application charts and daily records had not been completed. Service user agreements had not been signed and people had not received written information to make a complaint if they needed to. Staff had not received any formal training to understand their role and responsibilities. Staff were introduced to people and shadowed more experienced staff. They were observed by the registered manager to make sure they had the skills they needed.

However, people using the service at the time of the inspection told us they could speak with the registered manager if they had a problem. Feedback on the service had been requested. People told us they had contributed to their care plan and their needs were being met. People had a list of activities in their care plan and were supported to remain independent through exercise. People’s privacy and dignity was maintained, and people valued the support and the company staff provided for them. People had their dietary needs met. Health professionals were involved to support people’s ongoing health care needs. People were protected from the risk of cross infection. People using the service told us they were pleased with the service, they appreciated the managers level of involvement and felt cared for. People told us they have regular staff who stay the allocated time.

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 did support 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

This service was registered with us on 28 March 2017 and this was the first inspection.

Why we inspected

This was a planned inspection, there was no 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.