19 May 2022
During a routine inspection
People's experience of using the service and what we found
The provider had failed to ensure the quality assurance processes in place were effective. We found limited audits and no plans for service improvement. Care records were personal and involved people however we found specific information missing.
Systems were in place to make sure staff were recruited safely. This included a criminal record check (DBS) and references from previous employers. Staff were knowledgeable about people's needs and preferences.
There was sufficient staff to meet people's needs. Staff told us they had enough time to get to calls and people told us calls were on time.
All the people and relatives spoke positively about the care. People told us they were supported by staff who were kind and caring. One person said, “All the staff are very respectful and understand that I have full capacity.”
The feedback about management and leadership was positive. Staff told us they felt supported and the leadership team were approachable. One relative said, "The manager is very good and always listens to any comments we have and will address small issues immediately.”
The registered manager was receptive to the inspection process and we saw evidence the provider had started to address the issues identified during the inspection.
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.
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 11 June 2020 and this is the first inspection.
Why we inspected
The inspection was prompted in part due to concerns received about people's safety. A decision was made for us to inspect and examine those risks.
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 good governance 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 for 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.