Background to this inspection
Updated
4 February 2023
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 2 inspectors.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own homes.
Registered Manager
This provider is required to 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 to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
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 available to support the inspection.
What we did before the inspection
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 5th April 2022 to help plan the inspection and inform our judgements.
We used all this information to plan our inspection.
During the inspection
We spoke to the registered manager, reviewed care plans, medication records, training data and staff files in relation to recruitment. After the site visit, we spoke to 1 person and 2 relatives. We spoke with 2 members of staff and 1 professional.
Updated
4 February 2023
About the service
Three Roses is a domiciliary care agency providing the regulated activity personal care. The service provides support to people living with dementia and older people. At the time of our inspection there were 11 people using the service. The service provides support to people in their own homes who live in Bath and surrounding areas.
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.
People’s experience of using this service and what we found
Staff were not always recruited using safe recruitment principles.
Staff had received mandatory and induction training. They were supplied with personal protective equipment and had received appropriate training on how to use it safely. Staff had received supervisions and were supported by the registered manager.
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. At the time of the inspection the recording systems were moving from paper to electronic systems, which had resulted in some confusion about which system to use.
People and their relatives we spoke to were very happy with the support they received, they felt listened to and involved in their care. They felt safe and respected.
People’s care plans were not always kept up to date and lacked the detail needed to ensure that someone could step in and safely support a person.
Staff evidenced they understood how to support people.
The registered manager had not introduced any quality systems for monitoring service delivery to make improvements and there were no records of lessons learnt.
The registered manager told us she was only accepting referrals when she had capacity however, the registered manager was having to work with people for a lot of the week. This left her unable to fulfil her management responsibilities.
Staff, people and their relatives told us they knew how to complain and were confident they would be listened to by the registered manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 19 August 2021 and this is the first inspection.
Rating at last inspection
This service was registered with us on 19 August 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.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement and Recommendations
We have identified breaches in relation to medicines management, staffing and good governance at this inspection. 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.