Background to this inspection
Updated
28 June 2023
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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave the service short 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. We visited the location's office and visited people in their homes on 23 May 2023.
What we did before the inspection
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 liaised with the local authority safeguarding team. We reviewed notifications and information we held about the service. We used all this information to plan our inspection.
During the inspection
We spoke with 3 people who used the service about their experience of care and support provided. We spoke with 2 deputy managers, the care manager and 3 members of care staff. We reviewed a range of records. This included 4 people's care and support plans, 4 people's medicines administration records (MARs), 4 staff recruitment files, supervision records for 4 staff, the provider's business continuity plan, the staff training matrix and the provider's policies for equal opportunities, duty of candour, medicines management and staff training. A variety of records relating to the management of the service were also reviewed.
Updated
28 June 2023
About the service
Pembroke Care (Reading) Domiciliary services is a domiciliary care agency. It provides personal care and support to people living in their own homes or assisted living houses and flats. At the time of the inspection 11 people were using the service.
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
Risks to people’s safety were not always fully assessed and documented in their care plans.
People’s medicines were not always managed safely. PRN protocols were not in place for people who were prescribed ‘as required’ medicines.
Records of staff training were incomplete. They did not include information about how often training should be completed or when staff training was due. We have made a recommendation the provider improves their records of staff training to ensure they are complete and accurate.
There were shortfalls in governance and leadership. Systems and processes were not in place to ensure the provider maintained a detailed oversight of the service and of the necessary improvements needed to ensure quality and safety for people living there. There was a lack of evidence to demonstrate people's feedback was sought and acted upon and to demonstrate staff reflected on practice to improve care delivery.
People were protected from the risk of abuse and there were sufficient numbers of staff to ensure people received continuous care from staff they knew. People were protected from the risk of acquiring an infection.
People’s needs, choices and preferences were assessed and regularly reviewed and updated. Staff completed training to help them meet people’s needs. People were supported to maintain a healthy diet and adequate fluid intake. Staff worked collaboratively with external professionals to help meet people’s health and wellbeing needs.
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 and systems in the service did not support this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was good (published 8 January 2020). At this inspection the service has been rated requires improvement.
Why we inspected
The inspection was prompted in part due to concerns received about an incident of abuse perpetrated against a person by a staff member. As a result we undertook a focussed inspection to review the key questions of safe, effective and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pembroke Care (Reading) Limited on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment, staff training, and good governance. 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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.