Background to this inspection
Updated
23 May 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 team consisted of 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 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.
Inspection activity started on 4 April 2023 and ended on 18 April 2023. We visited the location’s office/service on 18 April 2023.
What we did before inspection
We reviewed information we held about the service, and we sought feedback from the local authority and professionals who work with the provider. 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
During the inspection we spoke with the registered manager and 2 staff members. We spoke with 3 people who were supported by the provider, the local authority commissioners, and a health professional. We reviewed 2 people’s care records including assessments and medication records. We reviewed 3 staff recruitment, induction, and training records. We also looked at policies and procedures and staff rotas.
Updated
23 May 2023
About the service
Mus4Banj Ltd is a domiciliary care agency providing personal care to people in their own homes. At the time of the inspection, Mus4Banj Ltd were supporting 8 people.
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 safely. There were gaps in employment records and disclosure and barring service checks were not always completed when staff commenced employment. The provider did not complete any audits to monitor and improve the service. A statutory notification of an event which affected the operation of the service had not been submitted to the Care Quality Commission.
Care plans were not always fully reflective of people’s needs. People were involved in planning their care and felt the registered manager and the staff were kind and caring. The provider had received several compliments thanking them for their hard work and dedication, particularly for providing dignified end of life care and support. Processes were in place for responding to complaints.
People’s choices and preferences were captured as part of the providers assessment process. The provider worked with health and social care professionals to achieve best outcomes for people. Staff received an induction and training in line with their job role, however, evidence of training certificates were not stored at the registered office. We have made a recommendation about the provider obtains and retains copies of staffs training certificates. The provider was completing unannounced spot checks on staff; however, they were not recorded. We have made a recommendation the provider ensures all staff checks are recorded, including feedback from people.
Risks to people were assessed and mitigated. Staff were aware of safeguarding processes and people felt confident to raise any concerns they had. Medicines were safely managed. Infection control procedures were followed.
The provider understood their responsibilities under the Mental Capacity Act. 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.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection
The service was registered 4 July 2022 and this is the first inspection.
Why we inspected
This inspection was prompted in part following concerns received about safe care and support. A decision was made for us to inspect and examine those risks.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement and Recommendations
We have identified breaches in relation to good governance and fit and proper persons employed at this inspection.
We have made a recommendation; the provider ensures they obtain copies of staff training certificates. We have made a recommendation to ensure all checks are recorded including any feedback obtained from people.
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.