Background to this inspection
Updated
21 February 2023
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
The inspection was carried out by 2 inspectors and an Expert by Experience. 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.
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 the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that a member of staff would be available to support the inspection.
Inspection activity started on 06 December 2022 and ended on 19 December 2022. We visited the location’s office on 06 December 2022.
What we did before the inspection
We reviewed information we had received about the service since registration. We sought feedback from the local authority, Healthwatch and a local advocacy organisation. 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. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.
We used all this information to plan our inspection.
During the inspection
We spoke with 5 people who used the service and 7 relatives about their experience of the care provided. We spoke with 4 staff, this included the registered manager, who is also the 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. This included 3 people's care records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including audits and policies and procedures, were reviewed.
Following our visits to the office, we continued to seek clarification from the provider to validate evidence found. We looked additional information offsite the provider sent us including; policies, rotas and quality assurance records.
Updated
21 February 2023
About the service
Willow Homecare Leeds Limited is a domiciliary care agency. The service provides personal care to people in their own homes. At the time of our inspection there were 12 people using the service. 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's systems and processes were not always effective in assessing, monitoring and mitigating risks to the health, safety and welfare of people using the service. The provider had quality monitoring processes in place, but these were not being routinely done. This placed people at risk of harm.
The provider did not always manage medicines safely. Systems in place to manage medicines were not always effective. Care records did not always include clear and up to date information about current medication and the level of support people required to take their medicines safely. This placed people at risk of harm.
Governance systems were not always in place to ensure all aspects of the service were reviewed and checked regularly. This placed people at risk of harm.
New staff received an induction program and staff had completed a range of training which gave them the skills and knowledge to care for people in their own homes. People and their relatives told us staff had the skills to support them in a safe and caring way. Staff told us they felt supported by the provider. We have made a recommendation about the safe recruitment of staff.
People were supported by staff who knew them well and were able to identify people's likes and dislikes. They said staff were kind, caring and patient. People were treated with dignity and respect. Staff cared about and had positive relationships with people. People and relatives considered the care they received to be safe.
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 12 October 2020 and this is the first inspection.
Why we inspected
This was a planned inspection based on the date of registration and the date regulated activity started.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We have identified breaches in relation to assessment of people's needs, risk assessments, management of medication and the provider's systems of 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 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.