Friary Meadow

Updated 24 May 2022

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 completed by two inspectors.

Service and service type

Friary meadow is registered to provide care and support to people living in 'extra care' housing and is also a registered domiciliary care agency providing personal care to people living in their own homes. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. People's care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people's personal care and support service.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was not a registered manager in post. The service was managed by an interim manager who is referred to as the manager in this report.

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 manager would be in the office to support the inspection.

Inspection activity started on 8 April 2022 and ended on 20 April 2022. We visited the location’s office on 8, 11 and 13 April 2022.

What we did before the inspection

Before the inspection we reviewed the information, we had received about the service, including notifications. Notifications are information about specific important events the service is legally required to send to us.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with three people who received care and four staff members, the manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records including, four people's care records, staff training matrix and risk assessments. We looked at a variety of records relating to the management of the service, including, policy and procedures.

We sought clarification from the manager and nominated individual to validate evidence found.

Updated 24 May 2022

About the service

Friary meadow is a domiciliary care agency and 'extra care' service. It is registered to provide personal care to people who live in their own apartments within a dedicated housing scheme. The complex consists of apartments, houses and bungalows privately owned. There are also some shared communal areas and facilities; such as a restaurant, café, cinema and gardens which people can access.

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 our inspection there were four people using the service.

People’s experience of using this service and what we found

There was a lack of systems and management oversight to ensure care was provided in a safe effective way. The nominated individual and manager told us there were no quality assurance systems placing people at risk due to poor governance and record keeping. Systems were not in place to identify areas for improvement and to ensure improvements were made.

Medicines were not safely managed. Medicine audits were not completed, and medicine care plans did not include all information required for staff to ensure safe management of medicines for people.

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 were protected from potential abuse by staff who had received training and were confident in raising concerns. There was a thorough recruitment process in place that checked potential staff were safe to work with people who may be vulnerable.

People's care plans contained personalised information which detailed how they wanted their care to be delivered. Staff knew people and expressed care and affection for them when speaking with us. People were

supported by kind and caring staff who worked hard to promote their independence and sense of wellbeing.

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 17 February 2020 and this is the first inspection.

Why we inspected

This was a planned inspection based on the date the service was registered.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the safe management of medicines and governance and quality monitoring of 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 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

return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.