Chapel And District Bespoke Care Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for Chapel and District Bespoke Care Ltd since they registered with CQC. This key question has been rated good. This meant people were safe and protected from avoidable harm.
 

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People were encouraged and supported to raise safety concerns with the provider. The registered manager and staff understood the importance of analysing and reporting safety concerns and learning lessons when things went wrong. For example, the provider took immediate action to address the shortfalls we found in some of their documentation, demonstrating their proactive approach and commitment to address any shortcomings.

The provider had an accident and incident tracker in place to record safety events. Any learning was shared with staff who were involved in the process and understood what actions were taken to mitigate future risks and keep people safe. The provider looked for opportunities to learn and evaluate the service and ways to improve practice.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We observed the process the provider had in place for all new referrals, documenting the initial information. This process was reviewed whilst we were on site and amended and expanded to address the shortfalls and ensure a more consistent approach would be taken. An assessment of need was completed, before deciding whether they would be able to provide the requested level of support. Despite some care plans lacking clear guidance, staff demonstrated a good understanding of the people they supported. Staff knew people well and provided care in line with people’s wishes. This meant people continued to receive individualised, compassionate care even when written guidance was not always fully detailed.

The provider had standardised policies and procedures in place to ensure the way they supported people reflected best practice in terms of safety and effective ways of working.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe receiving care; however, they preferred to be supported by their regular care workers. People shared how they also had access to others outside of the service with whom they could raise any concerns about their safety. For example, visiting health care professionals and their relatives.

Staff received regular safeguarding training. The provider had a comprehensive safeguarding policy and procedure in place, and staff told us they knew how to report any concerns.

The registered manager carried out investigations and co-operated with any safeguarding enquiries required by the Local Authority. Their findings were used by the registered manager to identify any lessons learned and any further actions to be taken to ensure people were protected from abuse.
 

The provider worked with people to understand and manage risks; however, information was not always captured in a clear way to support staff. Staff provided care to meet people’s needs and enabled people to do the things that mattered to them.

People’s individual risks were reviewed by staff, leaders and specialist teams where needed. While risks were identified and general guidance was available for staff, some care plans and risk assessments lacked sufficient detail to help guide staff to provide support safely and consistently. There was no negative impact on people because we found staff demonstrated strong knowledge of people’s current needs. The provider took immediate action to improve and personalise the detail in these plans. People we spoke with after our site visit, confirmed they had recent changes and updates made to their records. Staff confirmed, they were updated, “[Office name] always gives me a handover with essential information and any changes in needs.”

The provider reviewed any incidents for recurrent trends or triggers. Information about changes in people’s care needs was shared with the staff so support arrangements could be changed to reduce recurrences. People, and their relatives where appropriate, were involved in deciding how their individual risks would be managed and mitigated.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

In people’s own homes, CQC does not regulate the environment in which people live. However, we do ensure people’s safety is still assessed and monitored.

People were cared for in their own homes. The provider had environmental safety assessments in place to identify any potential risks in the person’s home which may have an impact on the person or their care staff. This included access, pathways, steps, handrails, and lighting, floor coverings, surfaces, cleaning products, gas and electrical appliances. Any potential environmental concerns were discussed with the person receiving care, as the provider was mindful it was the person’s own home. The service made sure equipment and technology were appropriate and supported the safe delivery of care. People did not raise any concerns about being involved in the management of risk.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had made sure all staff were suitably recruited, competent and able to carry out their role. We reviewed the training records for staff and found it included mandatory training. Staff commented that training was good and gave them the skills to carry out their role, however, others told us they preferred face to face training rather than online. This was fed back to the provider.

Some people and relatives raised concerns around the timing of their care calls and staff not staying their allotted time, whilst others had no concerns. The provider confirmed they monitored the time and call durations and investigated where there were any changes leading to increased call times or in relation to staff management.

The provider had a recruitment procedure to ensure staff were suitable to work with vulnerable people. We reviewed a selection of staff files and found pre-employment checks had been completed prior to staff commencing in post.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The provider ensured their staff had access to the necessary personal protective equipment (PPE) to support effective hygiene and infection prevention. The provider’s infection prevention and control (IPC) policy and procedures set out the roles and responsibilities for staff around infection prevention and control to ensure this was managed safely.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People who required assistance with their medicines had them appropriately supplied, stored, and administered in line with relevant legislation. Although people’s medicines was sometimes managed by the person themselves, or their relatives, the provider worked with people to ensure they had the necessary prescribed medicines available to them.

People had up-to-date information about their medicines available in their care plans and the provider’s medicine records. The provider made sure people’s individual care plans specified exactly what support each person needed from care staff in respect of their prescribed medicines.

The provider carried out regular medicines audits to identify any errors in recording, or the timing of prescribed medicines being given to people.