Background to this inspection
Updated
29 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 Care Act 2014.
Inspection team
The inspection was carried out by 1 inspector and an Expert by Experience who made telephone calls. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
This service is a domiciliary care agency. It provides care provides personal care to people living in their own homes.
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.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider would be in the office to support the inspection.
Inspection activity started on 11 May 2023 and ended on 24 May 2023. We visited the office location on 11 and 24 May 2023.
What we did before the inspection
We reviewed information we had received about the service since it registered with CQC.
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.
We used all this information to plan our inspection.
During the inspection
We spoke with 5 people and 5 relatives of people who used the service about their experience of the care provided. We spoke with 9 members of staff including the registered manager, the quality manager, the regional manager, 2 senior carers and 4 care staff.
We reviewed a range of records. This included 4 people’s care records. We looked at 3 staff members files in relation to recruitment. We also looked at a variety of records relating to the management of the service, including policies and procedures.
Updated
29 June 2023
About the service
Ave Maria Care Services is a domiciliary care service providing personal care to people living in their own houses and flats. At the time of our inspection, there were 54 people receiving support in their own homes.
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
The provider had failed to adequately manage calls to ensure they were made at the agreed time. The provider had systems in place to monitor calls times which had identified these issues. However, at the time of the inspection actions taken had not been effective in addressing the issues of calls being made either earlier or later than the times arranged and agreed with people.
The provider was open and receptive to the Inspection and the findings shared with them. The management team acknowledged improvements were required and were taking additional actions with staff to address these areas.
The provider had systems in place to assess the risks to the health and safety of people and provide staff with detailed guidance to mitigate these risks and people told us they felt safe with the support of staff.
Staff adhered to infection control procedures and protected people from the risk of infection. Staff were knowledgeable in safeguarding adults' procedures. People we spoke with said they felt safe with the care and support of staff.
People were supported to have maximum choice and control of their lives and to ensure staff supported them in the least restrictive way possible and in their best interests.
Staff were caring and respectful and people were involved in their care and their wishes about how they wanted to be supported.
People we spoke with said staff provided good care and staff working for the provider told us they felt supported in their role.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for the service was good (published 12 October 2017).
Why we inspected
The inspection was prompted in part due to concerns received about the management of calls. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the responsive and well-led sections of this full report to see what actions we have asked the provider to take.
Enforcement
We have identified a breach in relation to good governance.
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.