Archived: Mayberry Care Services Limited

Updated 23 July 2019

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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of choking. This inspection examined those risks.

Inspection team: The inspection was carried out by one inspector on the 15 and 16 January 2019 and two inspectors on the 24 and 28 January 2019

Service and service type: Mayberry Care Services Limited is a domiciliary care agency. It provides personal care to people living in their own homes in the community.

The service had a manager registered with the Care Quality Commission. 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 visit because we needed to ensure someone would be available to assist us with our inspection. We visited the office location on 15, 16, 24 and 28 January 2019 to see the provider, manager and office staff; and to review care records and policies and procedures.

What we did:

Before the inspection we reviewed any notifications we had received from the service. A notification is information about important events which the service is required to tell us about by law. We also reviewed any information about the service that we had received from external agencies. We used this information to help us decide what areas to focus on during our inspection.

During the inspection we spoke with three people who used the service and three relatives. We spoke with four staff members, the nurse educator, the quality and training lead, the registered provider and registered manager. We raised our concerns and liaised with the local clinical commissioning groups who funded peoples care. We looked at seven people’s care records, training records, complaints and audits and quality assurance reports.

Updated 23 July 2019

About the service: Mayberry Care Services Limited is a domiciliary care service providing personal care to nine people many of whom had complex health care needs at the time of the inspection.

People’s experience of using this service:

People were not protected from avoidable harm and known risks were not responded to or mitigated. Shortfalls in the service meant people had been exposed to immediate risk of significant harm. The registered manager had not recognised or acted on safeguarding concerns. Lessons were not learnt when incidents occurred and this placed people at risk of ongoing harm.

The provider had not ensured staff had received training in all people’s healthcare needs and as such staff had been providing clinical care tasks without the specific training or oversight. This had put people at serious risk of harm. The provider had not ensured checks were carried out on staff competencies to ensure they were providing safe care. Where concerns about staff practice had been noted through observations of care these had not been addressed by the provider.

People could not be assured that concerns or complaints would be dealt with. There were no robust systems to deal with complaints or for the provider to learn from complaints received. Whilst care plans had been reviewed they had not always involved the person. Care plan reviews had not been effective in identifying where care plans were incomplete.

The provider had not ensured they had robust and effective systems in place to monitor the quality and safety of the service and had failed to recognise the widespread shortfalls in safety. As a result people were exposed to significant levels of harm on an ongoing basis.

More information is in the full report

Rating at last inspection: Good (Report published 1 March 2017)

Why we inspected: We brought the inspection forward due to serious concerns we had received about an unexpected death at the service. Whilst the investigation into the death is on-going we carried out this inspection to check on the safety of the other people receiving care from the service.

Enforcement: As we have rated the service as inadequate, the service will be placed in ‘special measures’. Services in special measures will be kept under review. Following the inspection we took urgent action to impose conditions on the providers registration to restrict admissions to the service. In the meantime the provider submitted an application to deregister and we therefore withdrew any further enforcement. At the time of the publication of this report there are no longer any people using the service which is now closed.