Excelle Home Care

Updated 20 December 2022

The inspection

This was a targeted inspection to check whether the provider had complied with the warning notice in relation to Regulation 17 (Good Governance).

Inspection team

The inspection was carried out by one inspector.

Service and service type

This service is a domiciliary care agency. It 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 we were informed that the service manager would be applying to become the registered manager.

Notice of inspection

Our inspection was announced. We gave the service notice of the inspection. This was because it is a small service and we needed to be sure that a member of the management team would be in the office to support with the inspection.

What we did before the inspection

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 also reviewed the information we already held about the service and provider. This included last inspection reports, enforcement and notifications. A notification is information about important events, which the provider is required to tell us about by law. We used all of this information to plan our inspection.

During the inspection

We spoke with 1 person that used the service, 4 relatives, the provider, the service manager, the field supervisor and 2 staff. We reviewed quality assurance records such as audit arrangements. As part of this, we reviewed a sample of risk assessments and staff call logs.

Updated 20 December 2022

About the service

Excelle Home care is a domiciliary care agency and is based in the London Borough of Havering. The service provides personal care to adults 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.

The service was supporting 11 people with personal care at the time of the inspection.

People’s experience of using this service

Some people and relatives told us staff had been late for care visits. Staff rotas showed that care calls were booked back to back with no time given to staff to travel in between appointments. This increased the risk of late and missed calls.

The provider’s audit systems, to monitor staff time keeping, were not effective.

Although staff were aware of risks associated with people, accurate records of risk assessments had not been kept consistently to ensure people received safe care. We made a recommendation in this area.

Quality assurance systems were not in place to ensure care plans and risk assessments were accurate to ensure people received safe care.

Systems were in place to record incidents and take appropriate action. Medicines were being managed safely. Pre-employment checks had been carried out to ensure staff were recruited safely.

Systems were in place to obtain feedback from people and relatives.

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 this service was Requires Improvement (published 14 February 2020). We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to staffing and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

The service remains rated Requires Improvement. This service has been rated Requires Improvement for the last three consecutive inspections.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Excelle Homecare on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to staffing and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.