Background to this inspection
Updated
11 May 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.
This was a targeted inspection to check whether the provider had met the requirements of the Warning Notices in relation to Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding) and Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on concerns we had about we had about lack of oversight of risk within the service to keep people safe.
Inspection team
The inspection was carried out by 1 inspector.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
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 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 people at home 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. 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
During the inspection, we spoke with 5 members of staff, which included the registered manager, the area manager, senior staff, and care staff. We used electronic file sharing to enable us to review additional documentation.
We reviewed a range of records. This included 4 people's care records and medication records. We looked at safeguarding records and we looked at a range of records relating to the governance and management of the service.
Updated
11 May 2023
About the service
Ave Maria Care Wolverhampton is a domiciliary care agency providing personal care to people living in their own homes. The service provides support to older people, younger people, and people with dementia. There were 23 people using the service at the time of our inspection.
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
Systems were developed and put in place in response to the concerns raised during the last inspection. These included concerns over safeguarding, care planning and governance. Improvements were made to the quality auditing processes and safe care and treatment. The provider also introduced specialist staff training to support people with specific conditions and they reviewed their auditing and governance systems to have a clearer oversight of the service provided.
The provider employed a new administer to support them with the monitoring and auditing processes and they developed a new senior carer role to assist with the oversight of people’s care and staff. The registered manager was keen to develop a culture of improvement, partnership working and transparency.
The provider monitored the quality of care and support provided to people. The provider completed regular audits of the care plans, risk assessments and medicine administration. Improvement was identified and acted upon in a timely manner.
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 requires improvement (Published 4 February 2023).
At our last inspection we found breaches of the regulations in relation to safe care and treatment, safeguarding and good governance, which meant there was a lack oversight of risk within the service to keep people safe. The provider was made aware of our concerns and the improvements which were required to be completed by 31 December 2022.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulations 12, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.
We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ave Maria Wolverhampton on our website at www.cqc.org.uk
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.