30 November 2022
During a routine 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
People’s care and support needs were not always provided in line with their assessed needs. The provider did not always ensure that there were suitable numbers of staff available to safely support people. Relatives told us they often had to provide support to people and had raised this with staff during care reviews, but this was not actioned or raised with the registered manager.
Notifications relating to significant events that had occurred at the service, for example allegations of abuse, had not always been submitted to the CQC. This is part of the legal requirement all registered managers and provider must follow to ensure they are meeting the regulations.
Relatives provided positive feedback about the approach of staff and how they treated people. People were supported to be as independent as possible and staff carried out enabling calls so that people could participate in actives and socialise within the community.
People were supported to have maximum choice and control of their lives 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.
Risks people may face were fully identified and mitigated. Medicines were safely managed, and the service worked in partnership with other health care professionals to make sure people received a continuous level of support.
People had person-centred care plans which were created from holistic assessments of people's needs. Staff had a positive relationship with the registered manager and felt able to provide feedback regularly about the service. The quality and assurance systems in place allowed for effective monitoring of the service by the registered manager and provider.
Staff had access to PPE and followed best practice guidance and the provider's policy in relation to infection prevention and control. Staff received training and support to make sure they had the right skills and knowledge to support people.
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 12 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 staffing levels and submission of notifications at this inspection. We have made a recommendation that the provider reviews the systems in place to ensure that any identified actions from care reviews can be monitored by the registered manager.
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.