Reflections Community Support

Updated 25 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 7, 12 and 13 September 2017 and was announced. The provider was given 48 hours’ notice because the location provides a domiciliary care service and we needed to be sure that someone would be available to support with the inspection.

The inspection team consisted of an adult social care inspector and an expert-by-experience on the first day of the inspection. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second and third days of the inspection were carried out by an adult social care inspector to follow issues up.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also looked at details we held about the provider on our systems and looked at notifications submitted by them about significant issues affecting the people who used the service. This showed us how they had responded to incidents that concerned the people who used the service. When planning the inspection we contacted the local authority safeguarding and quality performance teams to obtain their views about the service.

At the time of this inspection there were 24 people using the service. During the inspection we made a visit to the provider’s office and met the manager, a training manager, a care coordinator, an office administrator, as well as two care staff who were visiting the office.

We looked at the care files belonging to six people who used the service and a selection of documentation relating to the management and running of the service. This included staffing records, quality audits, minutes of meetings and performance reports.

During the inspection we made a visit to one of the people who used the service to ask them about the quality of provision they received. The expert by experience contacted four people who used the service and seven relatives by phone in order to obtain their views. Following our inspection visit we subsequently spoke with a further four care staff by telephone.

Updated 25 October 2017

This inspection took place on 7, 12 and 13 September 2017 and was announced on the first day. This was because we needed to make sure someone would be available to support with the inspection.

The service was last inspected in July 2016 when it was found to be in breach of Regulation 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were gaps in staff training and the systems in place to monitor and assess the quality and safety of the service were not effective or robust.

At this inspection we found improvements had been made to address the above breaches of regulation and the service was now compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Arrangements had been made to ensure care staff were provided with a range of training and supervision of their work to enable them to carry out their roles. A new computerised office system had been obtained to enable the quality of the service people received to be safely assured.

Reflections Community Support is a domiciliary care agency that is registered to provide personal care to people living in their own homes in the community. It primarily provides a service to older people to assist and support them in maintaining or improving their independence. The office is situated in a central location in Guiseley, which is an outer suburb of Leeds. At the time of this inspection there were 24 people using the service.

There was a registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Throughout this report we have referred to the registered manager as ‘the manager’.

People who used the service were supported by care staff who been provided with training to ensure they knew how to recognise and report incidents of potential abuse. There were suitable numbers of care staff available. Care staff had been safely recruited to ensure they did not pose an identified risk to people. Assessments about potential risks to people had been completed to ensure care staff knew how to keep people safe from harm. Training had been provided to care staff to ensure they knew how to administer medicines safely and additional training on this was planned to be delivered. People told us care staff did not rush and provided them with a consistent and reliable service.

People were consulted and involved in decisions about their support; their consent was obtained by care staff to ensure this was in line with their wishes and preferences. Care staff encouraged people to maintain a healthy diet and medical professionals in the community were involved when this was required.

Care staff had developed positive relationships with people and treated them with consideration and kindness. Care staff maintained people’s personal dignity. People told us that care staff supported them to be as independent as possible and respected their wishes for privacy. People’s support plans contained evidence of assistance provided to ensure their health and wellbeing was maintained.

People were encouraged to maintain their involvement in the community to ensure they were not at risk of social isolation. People told us they were happy with the service they received and were confident any concerns they might have would be appropriately addressed.

Recording systems had been developed to ensure the quality of the service could be effectively monitored. A range of audits and checks were carried out to enable potential trends and patterns to be analysed with action taken when this was required to help the service to learn and develop. People feedback and suggestions were welcomed to help the service continually improve. People told us that management was open and approachable and worked in partnership with them to help meet their needs. Care staff told us that management was supportive and that they enjoyed working for the service.