Background to this inspection
Updated
7 October 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
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 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.
Notice of inspection
We gave the service 24 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 available to support the inspection.
Inspection activity started on 23 August 2022 and ended on 26 August 2022. We visited the location’s office on 23 August 2022.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. 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 three people using the service and one relative about their experience of the care provided. We spoke with ten members of staff including the provider who is also the registered manager, the administration manager, care coordinator and care workers. We reviewed a range of records. This included three people's care records and medication records. We looked at five 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.
Updated
7 October 2022
About the service
Victory Social Care Enterprise is a domiciliary care service providing personal care and support to older people, younger adults and people with physical disabilities, living in their own homes. At the time of the inspection five people were being supported with personal care.
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 not effectively operated their quality assurance systems to oversee the safety and quality of the service. Shortfalls identified included staff training, lack of supervisions and poor medicines oversight.
There were also shortfalls in the quality of recording of information relating to recruitment. We have made a recommendation about this.
Despite the issues we found, people received person centred care. Relatives spoke positively about the care people received and the registered manager. They felt able to raise concerns and were confident these would be addressed. Staff knew people well and were knowledgeable about when to refer to other health professionals for advice and support. Staff provided a consistent, reliable service.
Staff developed and implemented individualised risk assessments which mitigated risks to people's safety and wellbeing. Care plans covered all aspects of people's lives and their preferences.
Systems were in place for communicating with people, their relatives and staff to ensure they were fully involved. Feedback from people and their relatives was positive.
People and their relatives were involved in making decisions about their care. Staff respected people’s privacy and dignity and promoted their independence. People and relatives were aware of the provider’s complaints procedure and felt confident to raise concerns.
Staff had good access to personal protective equipment to manage the risks associated with the spread of infection including COVID-19 and adhered to government guidance to protect people.
For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk
Rating at last inspection
This is the first inspection of this service which registered with CQC on 10 May 2021.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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 and will take further action if needed.
We have identified breaches in relation to staff support, training and lack of quality performance and oversight of the service.
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 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.