Background to this inspection
Updated
9 September 2021
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
This inspection was carried out by one inspector.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own homes.
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
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.
Inspection activity started on 2 August 2021 and ended on 10 August 2021. We visited the office location on 4 August 2021.
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 of this information to plan our inspection.
During the inspection
We spoke with the manager and the nominated individual. We reviewed a range of records. This included three people's care records and medication records. We looked at five staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, audits and policies and procedures were reviewed.
After the inspection
We spoke with one person who used the service and two relatives about their experience of the care and support provided. We also spoke with two staff about their experience of working for the service.
We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance records and policies.
Updated
9 September 2021
About the service
Pacific and Gold Healthcare is a domiciliary care service who provide care and support to people living in their own accommodation, predominantly within the Wakefield area.
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. At the time of the inspection the service was supporting six people with personal care.
People's experience of using this service and what we found
We found improvements were required with recruitment and governance procedures. The provider's monitoring systems were not effective as internal audits did not identify the issues we found on inspection.
People did not always receive safe care. Staff had not always been recruited safely into the service. Recruitment files had missing information, including how the service was reassured staff were suitable to work with vulnerable people. The service had failed to assess people for risks that would put them at harm. Whilst there were audits and checks in place to monitor the quality of the service these issues had not been identified by the provider’s quality assurance systems.
People were protected from abuse. Staff knew how to recognise and report abuse. People and relatives told us they received safe care. People received support from a regular and committed staff team. Staff were trained to administer medicines safely. Competency checks had been completed to ensure staff were following safe medicine practices. Staff had received training in infection control and demonstrated an understanding of what personal protective equipment (PPE) should be used when supporting people. People told us staff wore PPE whilst spending time in their homes.
Staff knew people well and supported them based on their needs, choices and preferences. They were knowledgeable about their role and the expectations of people who were in receipt of care. Staff received regular training which had provided them with the necessary knowledge to meet people's needs.
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 supported this practice. Care plans were detailed and up to date and contained person centred information.
The service promoted person centred care and had an open and honest culture. Staff spoke very positively about the registered manager and their colleagues, describing them as, approachable and supportive.
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 02 May 2019 and this is the first inspection.
Why we inspected
This was a planned inspection as the service did not have a rating.
Enforcement
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.
We have identified breaches in relation to staff recruitment and quality assurance at the service.
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 following this report being published 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.