10 October 2023
During an inspection looking at part of the service
Santos Care Limited is a small domiciliary care provider. At the time of our inspection there were 15 people using the service.
People’s experience of the service and what we found:
Care plans and risk assessments lacked detail, peoples wishes and preferences were not always recorded to ensure care was provided in a way they chose or wished. Some risk assessments were generic and not person centred. Risk assessments did not always contain information on how risks were managed or mitigated.
Health management plans were generic and contained details which could mislead staff in relation to what support fell within or outside of their competencies.
Care plans held conflicting information as to the care that was to be provided. What was written in the care plan did not always reflect the actual care taking place.
The provider had ineffective systems and processes in place to ensure full and effective oversight of the service and the quality of care provided.
People and relatives were not confident that staff were trained and competent in completing tasks as part of their or their relatives’ care.
Best interest meeting records did not capture full details of the decision to be made or why it was needed, also records did not always demonstrate all the relevant options had been explored.
Where people took medication, it was not clear who was responsible for the management and administration of medication.
People consistently received late calls.
Rating at last inspection and update
The last rating for this service was Requires Improvement (Published 26 April 2023).
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At our last inspection we recommended improvements to be made in regulation 9 (Person centred care, regulation 11 (Consent), regulation 12 (Safe care and treatment), regulation 17 (good governance), regulation 18 (Staffing). A warning notice was issued for the breach of regulation 12 (Safe care and treatment and regulation 17 (good governance). At this inspection we found the service remained in breach of regulations.
Why we inspected
When we last inspected Santos Care Limited on 7 March 2023 breaches of legal requirements were found. This inspection was undertaken to check whether they were now meeting the legal requirements.
You can see what action we have asked the provider to take at the end of this full report. Please see the Safe, Effective, Responsive and Well led sections of this full report. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Santos Care Limited on our website at www.cqc.org.uk.
Enforcement [and Recommendations]
We have identified continued breaches in relation to Regulation 9 (Person centred care), Regulation 11 (Consent), Regulation 12 (Safe care and treatment) and Regulation 17 (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
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this time frame and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.