Background to this inspection
Updated
25 January 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 Care Act 2014.
Inspection team
The inspection was carried out by one inspector.
Service and service type
This service is a domiciliary care agency. They provide personal care to people living in their own houses and flats. The service had a manager registered with the Care Quality Commission. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
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 the provider or registered manager would be in the office to support the inspection. Inspection activity started on 17/12/2021 and ended on 23/12/2021. We visited the office location on 17/12/2021.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority and clinical commissioning group. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with two relatives and a live-in carer (who was employed by another agency) about their experience of the care provided. We spoke with four members of staff including the registered manager, care manager and care workers. We reviewed a range of records. This included one person’s care record and medication record. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found.
Updated
25 January 2022
About the service
Walfinch Greater Manchester South is a domiciliary care service providing a service to two people, however only one person was receiving a regulated activity at the time of the inspection. 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
Safeguarding policies and procedures were in place and being followed. Appropriate risk assessments were in place and medicines were managed safely. Lessons learned and medication policies required updating, and this was done during the inspection. Infection prevention control (IPC) practices were being followed and the service had a good stock of personal protective equipment (PPE). The service was adequately staffed, though safe recruitment procedures had not always been followed. We made a recommendation the service reviews their recruitment procedure.
People were supported to be as independent as possible and their needs were considered. Staff received supervisions, but these were not happening in line with their policy. We made a recommendation for the service to review their supervision policy.
The service worked closely with a variety of professionals. Staff received training and worked towards obtaining a care certificate. People were supported to have maximum choice and control of their life, 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. However, staff lacked some understanding of the principles of MCA. The registered manager had not gained clarity about the capacity of the person. We made a recommendation to ensure MCA guidance and principles are being followed. Necessary consent forms were in place, but a pre assessment form had not been completed.
People’s equality and diversity needs were respected, and staff supported the person to be as independent as possible. Family members spoke positively about the service and were regularly in touch with the registered manager to discuss their relatives’ care package.
The service provided person centred care and a detailed care plan was in place, which was regularly reviewed. People’s communication needs were being met and the service had a policy in place to support this. Complaints were recorded and handled in line with their policy, though the policy required updating and this was done during our inspection. Although no one was in receipt of end of life care, the service had an end of life policy in place.
Some concerns were identified around the governance of the service, the audits in place did not identify the issues mentioned above. We made a recommendation to ensure audits are robust and policies are regularly reviewed. Confidential information was stored securely. Regular meetings were taking place with relatives. We reviewed several examples of positive feedback. Feedback surveys had been sent out and their responses had not yet been received. Staff and family members spoke positively about the management, a whistle-blowing policy and a lessons-learned policy was in place.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Why we inspected
This service was registered with us on 25/11/2020 and this is the first inspection.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.