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Updated 14 April 2022

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 Health and Social Care Act 2008.

Inspection team

This inspection was carried out by one inspector and an Expert by Experience. 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 personal care to people living in their own houses and flats.

Registered Manager

This service is required to have a registered manager. At the time of our inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 15 March 2022 and ended on 23 March 2022. We visited the location’s office on 16 March 2022.

What we did before the inspection

The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. Please see the well-led section of the full inspection report for further details. Before the inspection, we reviewed all the information we held about the service, including information about important events which the service is required to tell us about by law. We requested feedback from other stakeholders. These included the local authority safeguarding team, commissioning team and Healthwatch Leeds. 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 all of this information to plan our inspection.

During the inspection

We spoke with two people using the service and five relatives about their experience of the care provided. We gathered information from five members of staff including 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 two people’s care plans, risk assessments and associated information, and other records of care to follow up on specific issues. We also reviewed multiple medication records. We looked at three staff files in relation to recruitment, training and supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 14 April 2022

About the service

Main Site, also known as Pre Care Services, is a domiciliary care agency. It provides personal care to adults living in their own homes, some of whom required end of life care. At the time of the inspection, the service was supporting nineteen people.

People’s experience of using this service and what we found.

Improvements were required to ensure records in relation to people’s care and management of staff were complete and accurate. The provider’s internal audits were not effective and had not identified the issues found at this inspection.

There was no evidence medicines were not administered safely, however there were still several issues with the quality of medication records. The provider was not always following their own medication policy or best practice guidance and regulations.

We could not be sure the equipment used to support people was always safe. We found inconsistent quality in how risks to people’s care were documented.

Recruitment processes did not always evidence robust checks had been completed to ensure staff were safe to work with people using the service. Staff followed appropriate infection control procedures and enough personal protective equipment was available.

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 in the service supported this practice. However, we found the provider’s understanding around the application of the requirements of the Mental Capacity Act was not robust. We had a recommendation for the provider to review this area.

Staff told us they enjoyed their job and felt well supported through by management. We found there was a system in place to ensure staff were inducted and shadowed experienced members of staff. Staff received varied training; however specific training to meet the needs of people required end of life care had not been offered.

People and their relatives told us staff were caring and provided a service that made them feel safe, promoted their independence and had a positive impact in their lives. People were supported by staff who were caring and respected their dignity and privacy.

People and relatives told us they had been involved in setting up and reviewing their care and were confident that any concerns raised to the provider would be appropriately acted upon.

People, relatives and staff told us the service was well managed and managers were responsive, approachable and directly involved in the delivery of care.

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 30 December 2019 and this is the first inspection.

Why we inspected

This was a planned inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, effective and well led sections of this full report.

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

Enforcement and Recommendations

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 monitor the service.

We have identified breaches in relation to safe care and treatment, fit and proper persons employed and good governance at this inspection.

We made a recommendation for the provider to review good practice guidance in relation to the Mental Capacity Act.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.