Sure Grace Ministries Care Agencies

Updated 15 December 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 completed by two adult social care inspectors and an Expert by Experience. The Experts by Experience made telephone calls to people and their relatives to obtain feedback about their experience of the care provided. 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.

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 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 23 September 2021 and ended on 10 November 2021. We visited the office location on 23 September 2021.

What we did before the inspection

Before the inspection we reviewed the information we held about the service. This included details about incidents the provider must tell us about, such as any safeguarding alerts that had been raised. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We sought feedback from commissioners and the local authority safeguarding team. 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

We spoke with eight people and eight relatives of people who used the service about their experience of the care provided. We spoke with nine members of care staff, two office-based staff, and the registered manager. We reviewed a range of records. This included five people’s care records and their medication records. We looked at five staff files in relation to recruitment and a variety of records relating to the management of the service, including policies and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at electronic call monitoring records, staff recruitment records, medicine administration records, and quality assurance records, including policies and procedures were reviewed.

Updated 15 December 2021

About the service:

Sure Grace Ministries Care Agencies is a domiciliary care agency. It provides personal care to people living in their own houses and flats. Not everyone who used the service received personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. CQC only inspects where people receive personal care. At the time of the inspection 20 people were receiving personal care.

People’s experience of using this service:

People were not supported by effectively deployed staff to keep them safe and to meet their needs in a timely manner. Risks to people had been identified, but appropriate risk management plans were not in place. Staff training and assessment about their English communication skills was not effective. Care plans were not person centred and did not contain sufficient information about the level of support people needed from staff. The registered manager had not encouraged and empowered staff to be involved in service improvements. The provider’s quality assurance systems were not effective.

We have made two recommendations in relation to Medicine Administration Records(MAR), and to maintain robust systems and processes, to monitor concerns raised by people.

People were protected from the risk of infection. The provider trained staff to support people and meet their needs. The provider worked within the principles of Mental Capacity Act (MCA). Staff asked for people’s consent to their care. 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.

People’s needs were assessed to ensure these could be met by the service. Where appropriate, staff involved relatives in these assessments. Staff supported people to eat and drink enough to meet their needs and staff supported people to maintain good health. Staff supported people and they showed an understanding of equality and diversity and people’s privacy was respected.

The provider had a policy and procedure for managing complaints and to provide end-of-life support to people.

The registered manager and the provider remained committed to working in partnership with other agencies and services, to promote the service and to achieve positive outcomes for people.

Rating at last inspection and update

This service was registered with us on 07/08/2019 and this is their first inspection.

Why we inspected

This was a planned comprehensive inspection.

Enforcement

We have identified breaches in relation to person centred care, safe care and treatment, staffing, fit and proper persons employed, and good governance.

Please see the action we have told the provider to take, at the end of this report.

Follow up

We will meet with the provider following this report being published, to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.