Archived: Shebadan Domiciliary Care Service (Sonali Gardens)

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Shebadan Domiciliary Care (Sonali Gardens) on our website at www.cqc.org.uk.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission 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.

At our previous inspection we found that the provider was not acting in line with the Mental Capacity Act (2005) by ensuring that people’s capacity was assessed where necessary and that where people lacked capacity staff could demonstrate they were working in people’s best interests. At this inspection, we found that the provider had carried out appropriate assessments of people’s capacity and there were records of best interests discussions. Staff had received training about mental capacity and this helped to ensure they understood their responsibilities under the law.

At our previous inspection we found that care plans did not accurately reflect people’s current care needs and the care that was delivered. At this inspection, we found that care plans had been checked and revised and now accurately reflected the care that people received. Checks were carried out by managers to help ensure that this continued.

At our previous inspection there were not sufficient systems of audit to ensure that high quality care was delivered. At this inspection, we found that managers had carried out audits to ensure the quality of documentation and that people were satisfied with their care. Managers had also implemented an ongoing audit process to help ensure that this improvement continued and was sustained.

Shebadan Domiciliary Care Service provides personal care to people from the Bengali community who live in their own homes. At the time of our inspection there were 45 people using the service, including older people and people with physical disabilities.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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.

The service had a stable staff team which was drawn from the Bengali community. People who used the service had received support from the same staff for many years, and commented on the consistency of the staff, and how they had benefitted from staff who spoke their language and understood their cultural needs. People felt the service respected their dignity and privacy, supported them to make decisions about their care, and that staff treated them with respect.

The provider assessed risks to people and took appropriate measures to manage these risks, which were reviewed regularly. Staff had received training in safeguarding adults and understood their responsibilities to report when they thought people may be at risk. Staff were recruited in line with safer recruitment processes and checks on the suitability of staff were carried out before they started work and reviewed every three years. The provider did not administer medicines, but ensured that when they prompted people to take their medicines this was appropriately recorded.

Staff had received training in core areas relating to their roles, and the majority of the staff team had earned qualifications in care or were working towards achieving this. However, we found that staff lacked training in mental capacity, and this was reflected in how the service approached people’s consent to their care. Care plans were not always signed by the appropriate person, and the service did not assess people’s capacity to consent to their care.

There was a visit monitoring system in place which logged when staff had arrived. Staff did not always log out, and managers were addressing this. The system showed that staff were punctual and had sufficient time to travel between appointments. Staff were well supported by managers through team meetings and supervisions, and managers were responsive to people’s concerns, including complaints made regarding the service.

Care plans and care summaries were reviewed regularly to meet people’s changing needs, however these did not always accurately reflect the care that people received, including personal care and when people needed meals provided. Records of care delivered were not always complete, and there was insufficient audit of these by managers to detect inaccuracies and omissions.

We found a number of breaches relating to care planning, consent to care and auditing of records. You can see what action we told the provider to take at the back of the full version of this report.

During this inspection, we gathered evidence against five outcomes to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

When we inspected on 8 September 2014 we found people had experienced a good quality of care which met their health and safety needs. The provider had created action plans from risk assessments where any risk had been identified. We saw there was a monitoring system in place to ensure people's health and safety needs were appropriately protected to keep them safe. The management team had assessed each person to ensure their views were considered in the planning of people's care. People's care records contained accurate information to ensure staff understood how to deliver care.

Is the service effective?

Effective systems were in place to monitor the management of the service. We saw people's care plans and risk assessments were regularly reviewed and updated as and when their needs changed. Staff told us these plans were detailed and provided them with good information in how to meet people's needs. The people and their representatives had signed the care plans to agree to how they wanted to be cared for by staff. They told us their needs were being met.

Is the service caring?

People were supported by kind and caring staff. People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. We found the registered manager and care staff had a good understanding of people's needs and how to support and care for them. one person told us "the carers are fantastic."

Is the service responsive?

The provider took action to address feedback from conversations with people who used the service and from family members. We saw that the manager promptly investigated complaints and took appropriate action to resolve the situation and ensure people's needs were met. Telephone monitoring and six monthly assessments took place with people using the service.

Is the service well-led?

We saw the provider had systems in place to monitor the quality of services that people received. Staff received a robust induction which was closely monitored by the management team. Staff received training, supervision and support from management, which helped them to provide safe and effective care.

Each person who used the service or their family carer told us they were happy with the quality of care provided by Shebadan. One person told us, "I have no complaints whatsoever. Everything is brilliant." People told us that their care workers arrived on time.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

There were appropriate staff recruitment and selection systems in place. This meant that people were cared for, or supported by, suitably qualified, skilled and experienced staff.

Office staff monitored the service and checked that staff followed care plans. People using the service were asked for feedback about how their care was delivered.

There was an effective complaints system available. The agency responded appropriately to people's comments and complaints .

People said they were involved in decisions about their care and their care workers respected their wishes. They praised the care workers as friendly and reliable. Care records gave staff clear information to help them to meet people's needs safely.

The agency had policies and procedures in place to protect vulnerable adults. We spoke with one care worker who had a good understanding of the signs of abuse and how to report any concerns. This care worker said they were well supported in their role with access to training, individual supervision and staff meetings.

Senior staff monitored the service and checked that staff followed care plans. People using the service were asked for feedback.