Archived: Peterborough Office

There was a registered manager in place. However, they had resigned and an application for them to cancel their registration had been submitted to the Care Quality Commission and was being processed. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Not all risks to people had been fully assessed. Risk assessments that we saw lacked detail and did not fully explain what actions staff should take or be aware of.

Staff had received training regarding administration and recording of medicines followed by a competency check carried out by a member of senior staff. This meant that staff had been trained and assessed as competent to assist people with their prescribed medicines.

People had had their needs assessed prior to the service providing them with care. People's care plans contained information which showed their likes and dislikes and how they wished to be supported. However, the care plans we saw were vague and only gave brief details of the assistance that people required during their care visit.

There was a safeguarding process in place and staff had received training. However, people were not always protected from harm because incidents that might constitute harm had not always been appropriately reported.

There was a system in place to record complaints. However, the investigation and outcomes of complaints and how the information was to be used to reduce the risk of recurrence was not in place.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and could describe how people were supported to make decisions. Training had been provided by the service and staff were aware of current information and regulations regarding people’s consent to care.

The provider had a recruitment process in place. However this process was not always followed which meant that there was a risk that people who were not suitable to provide care were being employed. Staff received an induction when they started work and further training was available for all staff which provided them with the skills they needed to meet people’s care needs.

People and their relatives were involved in how their care and support was provided. Staff checked people’s health and welfare needs and acted on issues identified. People were supported to access health care professionals when they needed them. People were provided with a choice of food and drink.

People, relatives and staff were able to provide feedback and information informally but surveys regarding the service had not been sent out since the last inspection which was undertaken on 23 August 2016. Effective systems were not in place to monitor and audit the quality of the service provided. This meant that the provider had not always been able to identify areas for action and to be able to drive forward any necessary improvements. Notifications, that the provider was legally required to submit to CQC, had not always been received.

Staff meetings and supervision sessions were being undertaken regularly. Staff were supported by two interim managers, care supervisors, senior carers and administrators during the day. An out of hours on call system was in place to support staff, when required.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Registration Regulations 2009

You can see what action we told the provider to take at the back of the full version of the report.

This comprehensive inspection took place on 23 August 2016 and was announced. It was carried out by one inspector.

The provider is required to have a registered manager as one of their conditions of registration. A registered manager was in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the agency. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were kept safe and staff were knowledgeable about reporting any incident of harm. People were looked after by enough staff to support them with their individual needs. Pre-employment checks were completed on staff before they were assessed to be suitable to look after people who used the service. People were supported to take their medicines as prescribed.

People were supported to eat and drink sufficient amounts of food and drink. They were also helped to access health care services and their individual health and nutritional needs were met.

The CQC is required by law to monitor the Mental Capacity Act 2005 [MCA 2005] and the Deprivation of Liberty Safeguards [DoLS] and to report on what we find. The provider was aware of what they were required to do should any person lack mental capacity. People’s mental capacity was assessed and people were able to make decisions about their day-to-day care. Staff were trained and knowledgeable about the application of the MCA.

People were looked after by staff who were trained and supported to do their job.

People were looked after by kind staff who treated them with respect and dignity. They and their relatives were given opportunities to be involved in the setting up and review of people’s individual care plans.

Care was provided based on people’s individual needs and helped to reduce the risk of social isolation. There was a process in place so that people’s concerns and complaints were listened to and these were acted on.

The registered manager was supported by a team of management staff and care staff. Staff were supported and managed to look after people in a safe way. Staff, people and their relatives were able to make suggestions and actions were taken as a result. Quality monitoring procedures were in place and action was taken where improvements were identified and being required.