Background to this inspection
Updated
6 June 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 1 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, however they were not available at the time of our inspection.
Notice of inspection
We gave the service 48 hours’ notice of the inspection, which was then postponed at the registered managers request. We then re-arranged the inspection visit to take place 7 days later. This was 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.
What we did before inspection
We reviewed information we had received about the service. We sought feedback from the local authority who work with the service. The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. Please see the well-led section of the full inspection report for further details. In October 2022 we attempted a monitoring visit, however the registered manager did not attend the pre-arranged call. We used information gathered, such as people’s experience, as part of monitoring activity that took place in October 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.
During the inspection
We spoke with 2 people who used the service and 3 relatives about their experience of the care and support provided. We spoke with 4 care staff, which included the nominated individual, the team leader and 2 carers. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed care records for 2 people, 3 staff recruitment records, training records, staff rotas and documents in relation to the governance of the service. We also received feedback from three professionals who work with the service.
Updated
6 June 2023
About the service
Shining Star Home Care Limited is a care at home service providing the regulated activity of personal care to people. The service provides support to younger and older adults, some of whom may have dementia.
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 our inspection there were 10 people using the service, 8 of whom received personal care.
People’s experience of using this service and what we found
The provider processes and systems for governance and collaborative working with external stakeholders required strengthening. The provider needed to extend their knowledge of social care policy and procedures, to ensure they worked effectively with professionals involved in people’s care.
Other aspects of the service which required improvement was around the providers understanding of safe recruitment and when specific incidents were notifiable to the CQC. Improvements were needed to daily record keeping and the overall monitoring and reviewing of people’s records.
People told us they felt safe and supported by the staff who cared for them. Staff had a good understanding of how they protected people from harm and recognised different types of abuse and how to report it. Potential risks to people had been identified through assessments, however how this information was shared with people required improvement. There were enough staff on shifts to keep people safe and meet their needs safely. The provider did not have consistent assurances that people’s medicines were managed in a safe way. Safe practice was carried out to reduce the risk of infection. Where incidents had happened, lessons had been learnt and shared with the staff group. Recruitment checks for staff required further work to make this more robust.
Where people had support with their meals, they were given food they enjoyed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.
Changes in people’s care were communicated clearly and promptly to the staff team. Staff respected people’s choices they made about their care. Staff were trained to support people with their end of life care. People had access to information about how to raise a complaint.
People, relatives and staff told us the provider and registered manager was approachable and responsive to requests. They told us how they felt the provider had a caring approach to all those involved in the service.
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 25 June 2021 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 have identified a breach in relation to the governance 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.