Freesprings Ltd

Updated 7 December 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 one inspector.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave a short period notice of the inspection 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 02 November 2022 and ended on 09 November 2022. We visited the location’s office on 08 November 2022.

What we did before the inspection

We reviewed information we had received about the service since the provider registered in June 2020. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We reviewed a range of records including care records and staff recruitment records. We spent time with the registered manager exploring their understanding of their responsibilities regarding operating a safe and effective care service.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found. We looked at training data and quality assurance records. We spoke with a relative by telephone about their experience of the care provided. We received feedback from an external professional involved with the service.

Updated 7 December 2022

About the service

Freesprings Ltd is a domiciliary care service registered to provide personal care for older people, younger adults and people living with dementia, mental health conditions or physical disabilities living in their own houses and flats in the community. We discussed with the provider that they were providing a service outside the specialisms they had registered for.

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 this inspection there was one person using the service.

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

There were gaps in the registered manager’s knowledge about current best practice and statutory guidance. The registered manager did not ensure the care and support embraced people’s preferences of gender of the staff supporting them. Not all staff had received up to date training in the basic core areas which meant the registered manager could not be assured staff were providing people with safe, effective and person-centred care and support.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic. The staff and management team had not received training to support people living with a learning disability.

Care plans lacked detail about people’s likes and dislikes and general information about their physical and mental health conditions. The provider’s risk assessment process did not cover all aspects of people’s care and lacked detail to clearly tell care workers what to do to mitigate identified risks. People’s care needs and preferences were assessed before people started to receive support to help ensure their needs could be met. However, not all information learned through assessment and subsequently through working with people was incorporated into care plans.

The registered manager had not identified the concerns we raised during this inspection in relation to care records and risk management, staff training and competency assessments, record keeping and recruitment processes. The registered manager was open and honest throughout the inspection process. They acknowledged the shortfalls and identified improvements required. After the inspection site visit the registered manager developed an action plan to address all the identified shortfalls.

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.

The provider had enough staff to meet the person’s needs and to manage any changes. A relative said staff were punctual and had never missed a care call. Staff received training in infection control and had access to personal protective equipment, relatives said staff wore face masks when in people’s homes providing care and support. The registered manager had systems in place to help ensure learning from events, incidents or accidents that may occur.

The registered manager and staff provided safe support; this was confirmed by a relative. The registered manager was aware of their responsibility to report safeguarding concerns for external scrutiny and to notify CQC. At the time of this inspection no one receiving a service required support with medicines.

Staff provided kind and compassionate care. A relative said staff were polite, courteous and respectful to both the person using the service and to the wider family. An external professional said the care delivered was appropriate to meet people’s needs. People, and their relatives where appropriate, were involved in decisions about their care and support.

The person and their relatives were happy with the care they received and felt they were supported in their chosen way. Staff supported the person with their interests and social activities. The registered manager had a system in place to record and monitor complaints to help ensure they could identify any action required or if there were recurring issues. However, no complaints had been received at the time of this inspection.

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 18 June 2020 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 monitor the service and will take further action if needed.

We have identified a breach in relation to the overall management of the service 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 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 continue to monitor information we receive about the service, which will help inform when we next inspect.