Background to this inspection
Updated
7 October 2022
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.
Inspection team
The inspection was carried out by one 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 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 not a registered manager in post.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider would be in the office to support the inspection. Inspection activity started on 22 June 2022 and ended on 31 August 2022. We visited the location’s office/service on 23 June 2022.
What we did before the inspection
We reviewed information we held received about the service. We sought feedback from the local authority and professionals who might work with the service. The provider was not 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. We used all this information to plan our inspection.
During the inspection
We spoke with two relative of people who used the service about their experience of the care provided. We spoke with the nominated individual, who was also one of the directors for the provider, they are responsible for supervising the management of the service on behalf of the provider. We spoke with one care coordinator and three care workers for the service. We reviewed a range of records. This included four people’s care records. We looked at four staff files in relation to recruitment. We also looked at a variety of records relating to the management of the service.
We continued to seek clarification from the provider to validate evidence found. We looked at further evidence sent to us by the nominated individual regarding training, care plans and quality assurance.
Updated
7 October 2022
About the service
Freivan Support Services is a domiciliary care agency registered to provide personal care. At the time of the inspection, four people were receiving support with personal care.
People’s experience of using this service and what we found
Risks to people were not always recorded or mitigated against. Recruitment processes were not always robust. The provider was unaware of up to date guidance on infection prevention and control and did not record staff testing satisfactorily.
Care plans were not always person-centred; People needs were not always recorded correctly and we found an instance where information had been copied from one person’s care plan to another. Relatives told us people’s communication needs were met but the provider was not recording these in sufficient detail. People’s end of life wishes were not recorded. We have made a recommendation about this.
The provider did not have up to date oversight of staff training and had not made observations of staff at work.
Quality assurance systems and processes at the service were ineffective. The provider had not completed any spot checks at the time of the inspection nor audits of care plans or staff files.
At the time of inspection no one was being supported to have their medicines administered.
Staff were trained to safeguard adults from abuse and there had been no incidents or accidents at the service.
Assessments of people’s needs had been completed with people in line with the law. The service recorded people’s care in communication logs. People’s nutrition and hydration needs were met. People’s care was carried out in their best interests and staff understood the law in this regard.
Staff were respectful of people’s equality and diversity. People and relatives told us staff treated people well. People and relatives were able to make their views known to the service. People’s privacy and dignity were respected, and their independence promoted.
People and relatives told us they would feel comfortable to complain if required.
Staff were clear about their roles. Management were able to tell us how they would respond if things went wrong. The service sought to work with other agencies to the benefit of others.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 13 April 2021 and this is the first inspection.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to recording risk and governance at this inspection.
We have made two recommendations to the provider. We have recommended they follow best practice guidance around observing staff and recording people’s end of life wishes.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.