26 January 2022
During an inspection looking at part of the service
Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is 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 and what we found
The feedback we received from people who use the service and their relatives was positive. Relatives told us staff were kind and worked closely with them to monitor people’s well-being and support needs.
Records relating to people’s care and the management of the service were not always kept or sufficiently comprehensive. Improvement of the provider’s quality assurance systems was needed to ensure they were effective in identifying these recording shortfalls.
We found that people were supported by a small staff team who were familiar with their support needs and management of their medicines. People’s relatives told us staff arrived on time and communicated when they were running late and were confident in the skills of the staff who supported their family member.
Staff were aware of their responsibilities to record and report any concerns of abuse, accidents, incidents and near misses or changes in people’s wellbeing. Staff and people told us the registered manager provided care and was approachable and responded to any concerns.
The provider was reviewing their current systems to help them in delivering good quality care to people. They were open to receiving feedback from people and making improvements to the service.
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 25 February 2021)
Why we inspected
The inspection was prompted in part due to concerns received about cancellation of care calls by the provider due to staff shortages. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. This inspection was carried out to follow up on these concerns.
Whilst we found no evidence to support these concerns, we did however find some evidence that the provider needed to make further improvements in areas relating to their own quality assurance processes and record keeping.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified a breach in relation to the provider’s quality assurance systems and record keeping at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.