Background to this inspection
Updated
30 March 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 completed by 1 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 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 not a registered manager in post.
Notice of inspection
We gave the service a short period of notice of the inspection. This was because it is a small service and we needed to be sure that the provider or manager would be in the office to support the inspection.
Inspection activity started on 15 November 2022 and ended on 18 November 2022. We visited the location’s office on 15 November 2022.
What we did before inspection
We reviewed information we had received about the service. We used information gathered as part of our monitoring activity that took place on 27 October 2022 to help plan the inspection and inform our judgements. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with 4 staff including the manager and the compliance manager. We spoke with 1 person who used the service, and 1 relative.
We reviewed a range of documents including care plans, risk assessments, investigation reports, complaints logs, medicine records, staff recruitment files along with a number of the provider’s policies and procedures.
Updated
30 March 2023
About the service
Ave Maria Care (Leicester) is a domiciliary care service providing the regulated activity of personal care to people living in their own homes. The service provides support to older people or people with long term health conditions. At the time of our inspection there were 5 people using the service.
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
People were placed at risk of harm or experienced harm. Medicines were not always managed safely. Risk assessments did not provide robust guidance for staff on ways to reduce risks to people. Staff lacked knowledge and competency in some areas of care delivery.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this poor practice.
People were not always well treated and supported appropriately and feedback was mixed regarding people being able to express their views and be involved in decisions about their care.
People did not find it easy to raise concerns with the provider. This meant the provider could not be assured that complaints were logged and dealt with appropriately. The provider had a good understanding in relation to the Accessible Information Standard.
The service lacked governance and was not run smoothly. Managers were not clear about their roles, and issues identified at the inspection had not been picked up in audits completed by the provider.
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 10 October 2020 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
We have identified breaches in relation to the safety of medicines, risks to people not being managed safely, and a lack of leadership within the service this inspection.
Please see the action we have told the provider to take at the end of this report.
Due to the concerns found during this inspection, we have sent the provider warning notices. This gives the provider a specified amount of time to make improvements at the service.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.