Holy Spirit Home Care

Updated 6 July 2021

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 two inspectors.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave the service notice of the inspection. This was because due to Covid-19 restrictions we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 27 May 2021 and finished on 10 June 2021. We visited the office location on 27 May 2021.

What we did before the inspection

We reviewed information we had received about the service since registration. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections..

We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service and two relatives and also received written responses from two further relatives after the inspection. We asked them about their experience of the care provided. We spoke with three members of the care staff, administrator, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included seven people’s care records and daily notes recorded by care staff. We looked at the staff recruitment process, staff supervision and a variety of records relating to the management of the service, including policies and procedures and training records.

After the inspection

We asked the registered manager to provide us with a variety of policies and procedures and additional information. Most of this information was provided within the required timeframe. We used all this information to help form our judgements detailed within this report.

Updated 6 July 2021

About the service

Holy Spirit Home Care is a domiciliary home care service providing personal care to 30 people within 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

There were shortfalls in the way the provider assessed the risks to people’s health and safety. Care plan records and risk assessments were not always in place where needed. Where they were in place they did not always reflect people’s current health and care needs. Quality assurance procedures were not effective in identifying risk or potential risk to people’s health and safety. The assessment of the risks associated with medicines was not thorough. There were two breaches of the Health and Social Care Act 2008 (Regulations) 2014.

Accidents and incidents were recorded; however, there was little of evidence of reflective practice taking place to reduce the risk of recurrence.

Recognised best practice standards and guidance had not been used to assist with the forming of care plans nor to assist with acting on the risks to people’s health and safety.

We have made a recommendation to the provider about how to make improvements in this area.

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. However, the policies and systems in the service did not support this practice. Care plans identified people who were living with dementia. There was little evidence of the Mental Capacity Act 2005 being used to determine if decisions had been made for them in their best interest and supporting their rights.

We have made a recommendation to the provider about how to make improvements in this area.

People received support with their meals; however, robust care planning and risk assessment regarding the requirement for good nutritional health was limited.

There were enough staff in place to meet people’s care needs. Staff were recruited safely. Robust infection control and COVID-19 policies meant the risk of the spread of infection was reduced.

People praised the quality of the care they received. They found staff to be kind, caring and considerate. Staff provided people with dignified care that respected their privacy. Care was person-centred and people praised the way staff cared for them in their preferred way. Complaints were handled in accordance with the provider’s complaints policy.

People, relatives and staff praised the registered manager; they found her to be approachable, considerate and understanding. People told us they would recommend this service to others.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Why we inspected

This service was registered with us on 18 September 2019 and this is the first inspection.

You can see what action we have asked the provider to take at the end of this full report.

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.