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Inspection Summary

Overall summary & rating


Updated 30 December 2017

The inspection was announced and was carried out on 13 and 14 November 2017 by 3 inspectors supported by an expert by experience. This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats. It provides a service to older adults.

At the time of our inspection 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.

People were being protected against risks but the risk assessments we saw on people’s files failed to mitigate the potential hazards. The risk assessments we saw were not robust and merely described potential harm to people. We made a recommendation about this.

People’s needs and choices had been assessed when they started using the service, but changes to their needs had not consistently been identified or planned for. This meant that people were at risk of not receiving the care, treatment and support they needed. We made a recommendation about this.

Care plans did not always fully reflect people’s preferences. There was insufficient information recorded for staff to know how the person preferred to be supported, or their likes or dislikes. We made a recommendation about this. There was a system in place to review care plans, and reviews took place every 6 months. People and their relatives were involved in the reviews. The service took people’s communication needs into account when planning for and providing support. People’s complaints and concerns were responded to appropriately.

People were protected against potential abuse. The service had safeguarding and whistleblowing policies in place and staff we spoke to told us these were clear and easily accessible in the office. There were sufficient numbers of staff on duty to ensure the needs of people were being met. Recruitment systems were robust and made sure that the right staff were recruited to support people to stay safe. People were protected by the prevention and control of infection where possible. Staff were aware of the importance of using Personal Protective Equipment (PPE) when supporting people. Staff received infection control training. People received their medicines safely. The service had a medication policy which gave guidance to staff on how to support people with their medicines. Accidents, incidents and near misses were reported to management in line with the provider’s policy and procedure.

Staff were trained and competency checked by the registered manager. Staff at Terrablu worked with other organisations and professionals to deliver effective care. People had access to health and social care professionals. Records confirmed people had access to a GP, dentist and an optician and could attend appointments when required.

People’s rights had been protected and staff were acting in accordance with the Mental Capacity Act 2005. Staff demonstrated a good understanding of the MCA.

Staff were seen to be kind and compassionate towards people. Staff were encouraged to develop positive, caring relationships with the people they support. Staff told us they were able to spend time with people to get to know them, and wherever possible were matched with people in order to develop close working relationships. People’s dignity and independence was respected at all times.

People and staff spoke positively about the management of the service. Discussions with staff and people showed there was an open and inclusive culture at the service.

The service took steps to promote equality and inclusion within its workforce. The registered manager kept up-to-date with best practice and guidance in order to ensure she was able to lead the service effectively.

The registered ma

Inspection areas



Updated 30 December 2017

The service was safe.

Risks to people were not being routinely recorded but the service took immediate steps to address our concerns. .

People were safeguarding from potential abuse by the systems, process and practices in place.

There were sufficient numbers of staff to support people to stay safe and meet their needs.

People who received support with their medicines did so safely.

People were protected by the prevention and control of infection.


Requires improvement

Updated 30 December 2017

The service was not always effective.

People�s needs and choices were not always assessed in line with current best practice.

People�s nutrition and hydration needs were being met.

Consent to care and treatment was sought in line with current legislation and guidance.

Staff received training to meet people�s needs. An induction and training programme was in place for all staff.

Staff members worked collaboratively with other organisations to ensure the care people received was effective.

People had access to healthcare professionals.



Updated 30 December 2017

The service was caring.

People were treated with kindness and respect.

People were able to express their views and were involved in making decisions about their care.

People�s privacy and dignity was respected and promoted.



Updated 30 December 2017

The service was responsive.

People did not always receive care that was personalised to their needs.

People�s complaints and concerns were responded to appropriately.



Updated 30 December 2017

The service was well led.

There was an open culture where staff and service users were encouraged to input into the service.

The views of people were sought and acted upon.

The service sought to continuously learn from and improve on practices.

The service worked in partnership with other organisations.