11 July 2023
During a routine inspection
Margaret House is a domiciliary care agency providing personal care. The service provides support to older people and people who may be living with dementia. At the time of our inspection there were 25 people using the service who received a regulated activity. 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 provide a regulated activity, we also consider any wider social care provided.
People’s experience of using this service and what we found
Governance systems in place had not been effective at identifying areas for improvement. Records were not always in place or did not contain sufficient detail. Medicines management was not always in line with best practice. We have made a recommendation about this.
Staff knew people well and knew their individual needs and risks. However, risk assessments were not always in place or were not always sufficiently robust. Accident and incident forms were completed, but the reviews of these had not always been completed. Staff had sufficient PPE and understood their responsibilities in relation to managing the risk of spread of infection.
Staff received an induction and training. However, not all staff had been enrolled on the care certificate as part of their induction. Staff told us they felt well supported in their roles. Pre assessments were completed prior to people receiving their support. People were supported to have maximum choice and control of their lives and staff supported hem in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were supported by kind and caring staff, who they had developed positive relationships with. Staff respected people’s privacy and dignity.
People received person centred care in line with their wishes and preferences. However, further information was needed in their individual care plans. People's end of life wishes had been recorded and the provider was developing their end of life care plans.
Satisfaction surveys had been carried out to gather people views, these had been summarised, but no action plan developed. Staff felt well supported by the management team and felt it was a good company to work for. People felt confident to approach the management should they have any concerns.
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 08 April 2022 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 breaches in relation to governance at this inspection. Please see the action we have told the provider to take at the end of this report. We have also made a recommendation regarding medicines management.
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.