Jayrima Care Limited

Updated 17 December 2020

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.

This was a targeted inspection to check whether the provider had met the requirements of the requirement notices in relation to Regulation 17 (Good governance) and Regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Inspection team

This inspection was conducted by two inspectors.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses.

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.

Notice of inspection

We gave the service 48 hours’ notice of the inspection. This was because we needed to be sure that the registered manager would be available to support the inspection.

What we did before the inspection

Before the inspection, 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 feedback from other stakeholders. These included the local authority safeguarding team, commissioning team and Healthwatch Leeds. 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 of this information to plan our inspection.

During the inspection

We visited the service on 20 October 2020. Between the 15 October and the 3 November 2020, we sought information and documentation from the provider. We spoke with two people using the service, two relatives of people using the service and three members of staff, including care workers and the registered manager.

We looked at care records for two people using the service and requested information about medication records for three people. We looked at training and recruitment records for staff. We also reviewed various policies and procedures and the quality assurance and monitoring systems of the service.

After the inspection

We received emails from the registered manager with additional evidence. This information was used as part of our inspection.

Updated 17 December 2020

About the service: Jayrima Care Limited is registered as a domiciliary care agency providing the regulated activity ‘personal care’ to the people who live in their own homes. At the time of our inspection, the service was providing personal care to six people.

People’s experience of using this service:

Whilst we found no evidence to suggest medicines were not administered safely, issues were noted with some records related to medicines management. For example, hand written medicine entries on the administration records had not always been transcribed accurately. Risks to people were assessed but some risk assessments were either not required or did not contain sufficient information.

There was no staff training programme or support to enable them to perform their roles effectively. There was a recruitment processes in place but some of the information relating to safe recruitment had not been documented.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff gained people's consent before providing support. Although, mental capacity assessment or best interest decisions had not been completed for one person.

There was a system in place to respond to any complaints, however, not all information was documented. There was no effective system in place to monitor the quality of service and identify areas for improvement.

There were enough staff to meet people’s needs. An induction was completed by all staff.

People told us they felt safe and staff knew how to respond to possible harm. Staff followed infection prevention and control practices when supporting people in their own homes.

Staff involved healthcare professionals to ensure people's health care needs were met. People received support with eating and drinking, when required.

People and relatives said staff were reliable, kind and caring. Staff understood how individual people preferred their care and support delivered and the importance of treating people with dignity and respect. People's care plans were personalised, with enough detail for staff to provide effective care and support.

People and relatives had the opportunity to provide feedback on the service received. Information was provided so people knew who to speak with if they had concerns.

Rating at last inspection: The service was registered in June 2018, and this was the services first inspection.

Why we inspected: This was a planned inspection based on when the service was registered with the Care Quality Commission.

Enforcement: We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around staffing and good governance. Please see the ‘action we have told the provider to take’ section towards the end of the report. We also recommended the provider considers guidance and best practice on the Mental Capacity Act 2005, in relation to people who lack capacity, and act to update their knowledge and documentation appropriately.

Follow up: We will continue to monitor the service through information we receive. Further inspections will be planned for future dates as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk