3 August 2022
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.
The inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of 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 homes. The service had a manager registered with the Care Quality Commission. This means the provider and registered manager were legally responsible for how the service is run and for the quality and safety of the care provided.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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. At the time of our inspection there was a registered manager in post.
Notice of inspection
We gave the service 48 hours’ 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.
Inspection activity started on 14 July 2022. We visited the location’s office on 14 July 2022.
What we did before the inspection
The provider was asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. Prior to our inspection, we reviewed information we held about the service. This included any information received and statutory notifications. A notification is information about important events which the provider is required to send us by law. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
All the people at the service were living with sensory impairments and/or dementia so we were unable to speak with them. During the inspection, we spoke with two people's relatives, two care staff, the registered manager and the senior sister. We reviewed a range of records relating to people's care and the way the service was managed. These included care records for three people, staff training records, three staff recruitment files, quality assurance audits, medicine records, and records relating to the management of the service.
After the inspection
Following our visit to the office we continued to gather evidence and we contacted six care staff.
3 August 2022
About the service
Elmthorpe Convent Domiciliary Care is a domiciliary care agency providing care to people [sisters] of Saint John of God Hospitaller Services in their own rooms within a purpose built building laid out over two floors at Elmthorpe Convent in Oxford. At the time of our inspection five people were receiving the regulated activity of personal care from the service. Not everyone using the service received personal care. CQC only inspects where people receive personal care, which 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
People were kept safe from abuse and harm, and staff had the training, knowledge and experience to report any suspicions concerning abuse. The registered manager had systems in place to report and investigate concerns. Risks had been assessed and in place to manage the risk of harm to people. There were sufficient staff available to keep people safe and meet their needs. Recruitment processes and checks were in place to allow the registered manager to make safe recruitment decisions.
Staff members were trained to enable them to safely meet people's needs. Records evidenced that supervision meetings for staff were held regularly and staff told us they were well supported to perform their roles. People were supported to have maximum choice and control of their lives and staff provided them with care in the least restrictive way possible and acted in their best interests; the policies and systems in the service promoted this practice.
People's care plans were person-centred and focused on what was important to people. Care plans were regularly reviewed, and people were involved in the reviews. Staff supported people to maintain their faith and familiar lifestyle within the convent setting. People felt part of their community, within the convent and remained in close contact with the convent sisters. Being part of their lifelong ‘family’ gave people a sense of purpose and wellbeing. This gave an atmosphere of calmness and serenity in the building.
Relatives and staff spoke highly of the management; they found them approachable and supportive. Staff were given appropriate responsibility which was continuously monitored and checked by the manager. There were effective systems to monitor, maintain and improve the quality of the service and the registered manager worked closely with the senior sister to ensure care and support were provided appropriately, and in keeping with the ethos and traditions of the order.
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
This service was registered with us on 12 April 2021 and this is the first inspection.
Why we inspected
This was a planned inspection of an unrated service.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.