Background to this inspection
Updated
25 May 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.
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 service is required to have a registered manager. 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.
At the time of our inspection there was a registered manager in post who was also the managing director.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be staff available to speak with us.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
During our on-site visit on the 14 April 2022 we reviewed a range of records. This included four people’s care records including medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed. We spoke with the provider and care coordinator.
On the 19 April 2022 we spoke with four people who used the service and two relatives by telephone about their experience of the care provided. We also spoke with four members of care staff.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and policies.
Updated
25 May 2022
About the service
Walfinch West Suffolk is a domiciliary care service providing personal care to people in their own homes. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. 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. At the time of this inspection there was 21 people using the service, 13 of these were receiving support with personal care.
People’s experience of using this service and what we found
Risk management plans required more information to ensure care staff were provided with the guidance they needed as to how risks to people’s health, welfare and safety were to be monitored and reduced.
Recruitment processes were not robust. Recruitment checks had not been completed on all new staff to check their suitability or competence to work with vulnerable people prior to commencing employment.
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, care and risk management planning did not include an assessment of people’s mental capacity. Staff were not provided with training in understanding their roles and responsibilities in relation to the Mental Capacity Act (2005) MCA.
People told us staff wore personal protective equipment. There were systems in place for regular testing of staff for COVID-19. The provider's oversight and quality monitoring systems needed improvement.
Staff demonstrated they knew people well and this was confirmed by people who used the service and relatives. However, we have recommended that communication plans are developed to support people to express their views and provide more detailed information as to their health care needs.
People told us they received their medicines as prescribed.
People told us staff were kind, caring and treated them with dignity. They told us they had not experienced any missed calls and if staff were running late, they were kept informed. People told us they received care and support from a consistent team of staff.
People knew how to contact the office and raise any concerns if needed.
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 18 March 2021 and this is the first inspection.
Why we inspected
This was a planned inspection as the service had not been inspected since registering.
We have found evidence that the provider needs to make improvements as we have identified breaches of Regulations in relation to provision of safe care and treatment, good governance and oversight of the service.
Follow up
We will request an action plan from the provider and meet with them 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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk