We carried out a review of the data available to us about Reflections Community Support on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Reflections Community Support, you can give feedback on this service.
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.
Reflections Community Support provides personal care to people living in their own homes in the community, to assist and support them in maintaining or improving their independence. At the time of this inspection there were 20 people using the service.
At the time of the inspection, the service had a manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.
We found gaps in training for staff and this included mandatory updates; for example, one member of staff was overdue moving and handling training, safeguarding and medication training. We found 16 of the 20 staff had not completed the fire safety course, health and safety training and infection control. Staff we spoke with had a good understanding of the Mental Capacity Act 2005 (MCA).
We found the provider had audit systems in place as part of their monitoring system. However audits lacked evidence of actions taken and were not routinely updated.
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Recruitment procedures were effective with appropriate checks made on people’s employment histories and with the Disclosure and Barring Service (DBS). We looked at the staffing rota; this showed us there was enough staff to meet the needs of people who used the service. We found people were protected against the risks associated with medicines because the service had appropriate arrangements in place to manage medicines.
Complaints were welcomed and were investigated and responded to appropriately.
People’s care plans contained sufficient and relevant information to provide consistent, care and support.
People told us they felt safe and got the support they needed with meals. People received good care which ensured their health care needs were met. Staff were aware and knew how to respect people’s privacy and dignity.
We recommend the provider hold staff meetings in a safe location to ensure confidentiality is always maintained.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the end of this report.
' Is the service caring?
' Is the service responsive?
' Is the service safe?
' Is the service effective?
' Is the service well led?
Below is a summary of what we found. The summary is based on speaking with the manager and responsible person in the agency, speaking with people who used the service, the staff supporting them and from looking at records.
Is the service caring?
We found people who used the service were asked for their views about their care and treatment and they were acted on. The agency had been operating for around seven months and this was their first inspection. The manager said she was working on sending out questionnaires and using telephone monitoring to get the views of people.
Is the service responsive?
We found evidence people were involved in planning their care and support, where possible. If a person had difficulty in making a decision about their care then the views of people's relatives were sought in order to gain an insight into what the person may have chosen. We saw that care plans were easy to follow with personalised individual support plans outlining how people preferred their care to be delivered.
One person receiving care from the agency said, 'They have listened to what I have had to say and action had been taken.'
Is the service safe?
Assessments of any potential risks were completed before any support or care was given so that the person receiving support could have their care delivered safely.
The staff we spoke with confirmed they had a programme of induction and received training to enable them to support people safely. Staff gave details of their training and how it informed their work.
Is the service effective?
People spoken with said the care staff often prompted or assisted them with agreed actions in their care plan.
We spoke with care staff who had a good knowledge of the people they cared for. They told us peoples' care plans and risk assessments were kept in the person's home and they had guidance on how people's needs should be met.
Is the service well led?
We saw evidence of a system which ensured people's care was reviewed regularly and daily notes were also regularly reviewed. There were system to record any complaints and the action taken. There had been no complaint to date.