During an assessment under our new approach
Date of Assessment: 6 February 2025 to 16 April 2025. We visited the service on 6 February 2025 and reviewed information remotely following our visit. The service is a care at home service providing support to adults of all ages living with dementia, mental health conditions, physical disabilities and sensory impairment. There were 89 people receiving support when we visited, of which 81 people were receiving the regulated activity of personal care. This was a responsive assessment due to the length of time since the service was registered and recent concerns raised to CQC about staffing and governance. We gave the provider short notice to ensure management were available when we visited the office.
We found 2 breaches of the regulations relating to recruitment and good governance. Staff recruitment was inconsistent. Not all staff had appropriate checks carried out with the Disclosure and Barring Service to ensure they were safe to work with vulnerable people. Management oversight and systems to support quality and safety were not robust. New governance systems had recently been introduced, but these were not yet embedded to ensure consistency of quality and practice. The management team were aware of the shortfalls in the service. With support from the local authority, they had already identified areas for development and were working on these prior to this assessment.
There were enough staff to meet people’s needs and promote choice. However, some people and staff told us visit times could improve. The management were taking steps to monitor visit times and make any necessary changes. Managers made sure staff received training. Although most staff felt supported, they had not received regular formal support such as supervision and appraisal. Medicines were administered as prescribed, but processes did not ensure staff were routinely checked to ensure they remained competent to give medicines safely. Staff worked well with professionals and relatives but we could not be assured about consistent care and good outcomes for people due to the lack of monitoring and oversight of people’s care.
People could raise concerns, but improvements were needed to how the service collected people’s views and learnt from their feedback. Where safety incidents were reported managers investigated incidents and learnt from these. People were protected and kept safe. Staff understood and managed risks. Staff made sure people understood their care to enable them to give informed consent. People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and were encouraged to maintain relationships with family and friends. People received fair and equal care.
We have asked the provider for an action plan in response to the concerns found at this assessment.