Background to this inspection
Updated
25 December 2021
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 Care Act 2014.
This was a focused inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 . We also checked whether the provider had met requirements of breaches regulation 12 (safe care and treatment), regulation 11 ( Consent), Regulation 18 (Staffing) and regulation 19 (fit and proper persons employed).
Inspection team
This inspection was carried out by one inspector.
Service and service type:
Free Spirit Support Service is a domiciliary care service and provides personal care to people living in the community. including people living with dementia, people with sensory needs, physical disabilities, learning disabilities and mental health needs.
The service had a manager registered with the Care Quality Commission who was also the provider. This means that they are legally responsible for how the service is run and for the quality and safety of the care provided.
There was a deputy manager in charge on the day of our visit. The provider had limited involvement and oversight for improvements made to the service as they provided limited support to how the service was being run.
Notice of inspection:
We gave the service one weeks' notice of the inspection visit because it is small, and the registered manager was unavailable. We wanted to make sure the providers representative would be at the service.
What we did
We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
At the provider's office we spoke with the deputy manager, we reviewed the care records for three people who used the service. We also looked at a range of other records relating to the running of the service, such as, three staff files and the quality monitoring of the service where improvements had been made. We contacted relatives of people who used the service and four care staff where we received limited response.
After the inspection
We sought further information from the provider to inform our inspection judgement. This included Medicine audits, policies and recruitment processes.
Updated
25 December 2021
About the service
Free Spirit Support Service is a domiciliary care service. The service provides personal care to people living in their own homes. At the time of the inspection there were five people using the service.
Not everyone using the service received the regulated activity of personal care. CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.
Peoples experiences
Work was still ongoing to ensure medicines administration records were up to date and accurate. Improvements were noted but they still lacked detail.
Risks were monitored and managed more effectively. However, improvement was still required to the detail of information to ensure staff fully mitigated any risk for people.
Enough staff were employed in ratio to the number of people using the service. Infection control was in line with government guidelines. Lessons learned identified shortfalls and improvement was ongoing.
The service followed the principles of the mental capacity act (MCA) to ensure people’s rights were adhered to. The service worked well with other professionals and made referrals as and when required.
The provider gave limited support to ensure the service run well. The deputy manager in place had identified shortfalls and was enthusiastic to succeed.
Improvements were identified but not sustained at this time. Policies and procedures were still being developed. Governance required more detail to ensure it was fit for purpose.
Rating at last inspection
The last rating for this service was requires improvement (published 02 August 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made/sustained and the provider was still in breach of regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
This report only covers our findings in relation to the key questions Safe, Effective and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led
We have made a recommendation about the management of some medicines.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.