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
This inspection was carried out by 1 inspector and 2 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 that the registered manager would be in the office to support the inspection.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
We sought feedback from the local authority who work with the service. We reviewed the information we already held about the service. This included their registration report and notifications. A notification is information about important events, which the provider is required to tell us about by law. We used all of this information to plan our inspection.
We used information gathered as part of monitoring activity that took place on 03 February 2023 to help plan the inspection and inform our judgements.
During the inspection
We reviewed a range of records. This included 5 people's care records and risk assessments and 4 people's medicines records. We looked at 4 staff files in relation to recruitment and staff supervision. We reviewed a variety of records relating to the management of the service, including audits, staff training, satisfaction surveys, policies and procedures. We also spoke with the registered manager, compliance manager, service manager, HR manager and administrator.
We continued to seek clarification from the provider to validate evidence found. We requested additional evidence to be sent to us after our site visit. We looked at training data and quality assurance records.
As part of our inspection, we spoke with 3 care workers, 4 people who used the service and 7 relatives by telephone about their experience of the care provided.