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 the regulated functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act and looked at the quality of the service to provide a rating for the service under the Health and Social Care Act 2008.
Inspection team
The inspection team consisted of 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience using or caring for someone who uses this type of care service.
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 must 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 (CQC) to manage the service. Registered managers and providers are legally responsible for how the service is run, the quality and safety of the care provided and compliance with regulations. At the time of this inspection, a registered manager was in post.
Notice of inspection
We gave the service 48 hours’ notice of the inspection. This was because it was a small service, and we needed to be sure that the provider or registered manager would be available to support the inspection.
Inspection activity started on 18 December 2022 when an Expert by Experience spoke to people and relatives by telephone. Visits to the service’s office took place on 10 and 16 January 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection; this included whistle-blowing information. We sought feedback from the local authority.
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.
During the inspection
We reviewed a range of records. This included 7 people’s care records to see how their care and treatment were delivered. Other information we looked at included 4 staff recruitment files and training records. We also looked at documents relating to service management and the provider's electronic operating system. We spoke with 2 people, 6 relatives and 6 staff, including the registered manager, regional manager, compliance manager and IT manager and 3 care staff.
Updated
28 June 2023
About the service
Ave Maria Care (Edgbaston) is a domiciliary care agency registered to provide personal care to people living in their own homes. 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. At the time of the inspection, the service supported 22 people.
People’s experience of using this service and what we found
Some people had experienced multiple missed care calls or care calls attended by insufficient staff to meet their needs safely. This meant these people’s needs had not been consistently met, and they had been placed at increased risk of avoidable harm. The provider had not followed their safeguarding policy. Safeguarding incidents had not always been reported to the local authority’s safeguarding team or effective actions taken to keep people safe. The provider’s governance systems were not effective, and the information recorded about some people’s care was not accurate, up-to-date or complete. We were told that all care records would be reviewed. We sampled two care records that were person-centred, and the area manager told us all care records would be reviewed.
Staff had not received consistent supervision. Missed care calls meant people’s health needs had not been consistently monitored, and some people had not received consistent support to prepare meals. This did not reflect a caring approach. People and their relatives were not always confident that the provider would act on concerns and complaints. People’s preferences for their care and their interests and aspirations had not been consistently assessed or recorded.
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 supported this practice.
Enough staff were employed to meet people’s needs and prospective staff underwent pre-employment to ensure they were suitable to support people in their own homes. Steps were taken to protect people, their relatives and staff from the risk of infections.
People’s care needs were assessed before their care started. Staff completed induction and training designed to give them the knowledge and skills needed to meet people’s care needs. Staff understood and promoted people’s independence and their right to make their own decisions.
People’s individual communication needs were assessed and taken into consideration. Staff felt supported by the management team. Systems were in place to gather people’s and relatives’ feedback on the service.
For more details, please see the full report, which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 13 March 2020).
Why we inspected
This inspection was prompted by a review of the information we held about this service. This included whistle-blowing information received about missed care visits, insufficient numbers of staff attending care calls and falsified entries by staff on the provider’s systems confirming visits as completed.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well Led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We have identified breaches in relation to safe care, protecting people from abuse and the governance of the service.
Please see the action we have told the provider to take at the end of this report.
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
We will work alongside the provider and local authority to monitor progress. We will continue to monitor the information we receive about the service, which will help inform us when we next inspect.