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Inspection Summary

Overall summary & rating


Updated 24 October 2018

The inspection took place on 2 October 2018. The inspection was announced which meant that we gave the provider 36 hours’ notice of our visit. This was because the location provides a domiciliary care service and we needed to be sure that the registered manager would be available.

Sally and Sarah is a domiciliary care agency. It provides personal care to people living in their own homes in the community. Not everyone using Sally and Sarah receives regulated activity the Care Quality Commission (CQC) only inspects the service being received by people provided with ‘personal care’ help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided.

At the time of the inspection there were 31 people using the service.

The last inspection of the service was carried out in July 2017 and we rated them as required improvement. We found that the service was not meeting all the requirements of Health and Social Care Act 2008 and associated Regulations. We found concerns relating to the effectiveness of the providers governance systems. The provider did not have suitable systems in place to regularly assess and monitor the quality of the service to reduce any risks relating to the health, safety and welfare of people using services and others.

Following this inspection, we asked the provider to complete an action plan to show us what they would do and by when to improve the service to at least a rating of good.

At this inspection we found that the provider had undertaken consistent work to make improvements to the quality monitoring of the service. Regular audits were now taking place with a plan of any actions required and outcomes. This meant that any risks relating to people’s health, safety and welfare was being significantly reduced by the provider picking up on these through their quality monitoring audits.

The service had a manager who was currently in the process of applying to become the registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that they felt safe by the service provided. Staff had a good understanding of safeguarding, what their responsibilities were and could clearly tell us what action they would take if they had any concerns about the way people were supported. Staff received safeguarding training.

People's care needs were assessed and detailed plans were now in place to meet people’s individual needs. Since our last inspection of the service the provider had made changes to their care plans to make them more person centred and detailed the support people needed. People told us that they were cared for by staff who knew them very well, promoted their independence and understood how to support them.

Where risks of potential harm had been identified for people we found that there were risk assessments in place that recorded actions staff were able to take to reduce the potential for harm.

Medicines were being administered and managed safely by trained and competent staff.

People were supported to have maximum choice and control over their lives. Staff provided support in the least restrictive way and encouraged people’s independence. Staff understood their responsibilities in relation to respecting people’s privacy and dignity.

There were enough staff in place to provide people with safe care. We saw that the provider regularly reviewed the staffing levels to ensure that people had the maximum amount of time with staff.

Good recruitment systems were in place to ensure that the people employed were suitable to work with vulnerable people.

A training programme was in place that enabled staff to provide person-centred care.

Staff received regular supervision and an annual appraisal which allowed the manager to plan further training to support staff development.

Staff had a basic understanding of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and had received training.

We saw that the manager had introduced a reflective support session called ‘Remember Me’ to support staff following their involvement in end of life care for people.

The service had an effective complaints process in place and people were aware of it and understood how to make a complaint should they need to. The service actively encouraged feedback from people.

Inspection areas



Updated 24 October 2018

The service was safe and the rating for this domain had improved to good.

People told us they felt safe with staff. Staff had a good understanding of their responsibilities around protecting people and keeping them safe.

Recruitment systems were in place and made sure that the right staff were employed to keep people safe. There were sufficient staff to meet the needs of the people.

Medicines were managed safely and there were now processes in place to check that people received their medication as prescribed.



Updated 24 October 2018

The service remained effective.

People�s needs were assessed and their care was planned with a person-centred approach.

Staff were supported through regular training, supervisions and appraisals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

Staff understood the key requirements of the Mental Capacity Act 2005 and how to support people making every day decisions.



Updated 24 October 2018

The service remained caring.

People were treated with kindness and respect by staff who understood the values of respecting people�s right to privacy, dignity and confidentiality.

People received regular care and support from consistent staff who knew them well, ensuring continuity of their care

People were supported to maintain family relationships and links with their local community.



Updated 24 October 2018

The service remained responsive.

People received care that was responsive to their individual needs. The service was responsive and flexible in meeting peoples changing needs.

The service welcomed feedback from people about their experiences of the care and support they received and used this information to shape the service development.

People would be supported at the end of their lives to ensure their preferences were followed.



Updated 24 October 2018

The service was well led and the rating for this domain had improved to good.

The service was being well led by the manager. Staff were positive about the manager and felt supported

There were systems in place to monitor the quality of the service, which included regular audits, meetings and feedback from people using the service, their relatives and staff. Action had been taken, or was planned, where the need for improvement was identified

Policies and procedures were in place and referenced current

legislation and good practice guidance.