14 June 2022
During a routine inspection
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 provider had started providing care for people with complex conditions. We were not assured the tasks being provided were within the providers scope of registration and all risks related to this fully explored and mitigated. Whilst some training had been provided to staff delivering these tasks, the records kept in relation to this were not always comprehensive or up to date.
People and their relatives told us they felt safe and were protected from the risk of abuse. Risk assessments had been carried out to identify and minimise any risks involved in people's care. People's medicines were managed safely. Staff were recruited safely and there were enough staff to meet people's needs.
Care plans were reviewed and updated as people's needs changed. People were supported by staff who knew them well and were able to identify people's likes and dislikes. 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.
Staff monitored people's health effectively and responded promptly if people became unwell. Staff worked well with other professionals involved in people's care to ensure they received the support they needed.
People told us they were treated with dignity and respect and were positive about the support they received.
A complaints procedure was in place and people told us they felt able to raise concerns when they needed to.
The provider monitored the quality of the service and had an action plan to address any areas identified for improvement.
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 09 April 2020 and this is the first inspection.
The last rating for the service under the previous provider was good, published on 13 November 2019.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We have found evidence the provider needs to make improvements. Please see the effective and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
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 and will take further action if needed.
We have identified breaches in relation to staff training and governance at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.