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Collingwood Care Services Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 August 2018

This inspection took place on the 14 and 15 May 2018 and was announced. A comprehensive inspection was completed to assess all of the key questions.

At the last inspection in July 2017 there was a breach of legal requirements in relation to good governance. It was found that the provider did not maintain accurate records in respect of each service user. The provider also did not have a system and process in place such as regular audits of the service provided to assess, monitor and improve the quality and safety of the service. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to meet the Regulation. The provider submitted an action plan but at this inspection we found the actions were not completed and the provider continued to be in breach of this Regulation.

Collingwood Care Services is a domiciliary care agency that operates from within the campus of Highbury College and provides personal care to people in their own homes in the community. It is registered to provide a service to older people and younger adults living with dementia, physical disability and sensory impairment. At the time of the inspection the service was supporting five people. There was an individual registered provider in place who also acted as the manager, there was no requirement for a registered manager at the service. Registered providers 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.

The provider had not ensured that quality assurance systems and processes such as audits were fully in place to monitor, assess and improve the service. The provider was not appropriately documenting, assessing and monitoring risks to the health, safety and welfare of people using the service.

The provider was not maintaining comprehensive and accurate records in relation to each service user. Information in the manual handling risk assessments was not consistent and sufficiently detailed to effectively inform staff members how to support people to move safely. People's diverse needs were not always well documented in their care plans.

There were gaps in the employment history of some staff records. Though the provider was aware of the reasons for any gaps, they had not documented them. Other recruitment checks such as Disclosure and Barring Service (DBS) checks were completed.

The amount of training staff received was variable and not sufficient to support service users effectively. The training matrix was not up to date and had multiple gaps. New members of staff were not completing the Care Certificate. The Care Certificate standards are nationally recognised standards of care which staff who are new to care are expected to adhere to in their daily working life to support them to deliver safe and effective care. We recommend that all staff complete the Care Certificate to ensure they are meeting the industry standard.

The provider and staff were not able to tell us any best practice guidance that they were following.

The provider told us that staff received training on how to support people in relation to the Mental Capacity Act (MCA) 2005 but it was not documented on the training matrix that staff had completed this training. There were not any individuals who required support in line with the MCA at the time of the inspection.

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

The provider told us there had not been any incidents, accidents, safeguarding concerns or complaints since the last inspection. We had not received any notifications about these type of events. A notification is information about important events which the provider is required to send to us.

People felt safe and staff knew people well.

Staff knew the signs of abuse and how to raise concerns about safeguarding.

Inspection areas


Requires improvement

Updated 10 August 2018

The service was not always safe.

Care plans and risk assessments were not always accurate, detailed and up to date, to provide staff with the guidance they needed to deliver safe care. Sufficient improvements had not been made following our last two inspections.

Quality assurance processes were not always in place and not completed to monitor and assess the service people received. This meant that there was a risk that the provider would not identify when safety was compromised.

Employment history gaps were not always recorded. Other recruitment checks were carried out.

There were sufficient numbers of staff available to support people safely.

Staff recognised the signs of abuse and knew their responsibility to raise concerns.


Requires improvement

Updated 10 August 2018

The service was not always effective.

Staff had completed variable and insufficient amounts of training. Staff had not completed the Care Certificate.

The provider and staff were not able to tell us about best practice or national guidelines that they were incorporating into their service provision.

Staff felt well supported and received supervision.


Requires improvement

Updated 10 August 2018

The service was not always caring.

Issues identified in other domains of this report demonstrated a lack of a caring approach being taken by the provider.

Staff supported people in a caring and compassionate way.

Staff treated people with dignity and respect.


Requires improvement

Updated 10 August 2018

The service was not always responsive.

People�s care plans did not always reflect their needs, choices, preferences, personal history and important information to ensure staff would know how to provide person-centred care when they did not know the person well. Care plan reviews had not identified gaps and errors in care plans.

Staff respected people's diverse needs, though their needs were not always well documented.

Staff responded to concerns and made referrals to healthcare professionals such as District Nurses and GPs.


Requires improvement

Updated 10 August 2018

The service was not well-led.

Records related to care provision were not accurate. This had not improved following our last two inspections.

Employment and training records were not complete. Quality assurance processes had not identified gaps in these records.

The provider did not have adequate systems and processes in place to monitor and improve the quality of the service as described in the Safe domain. Sufficient improvement had not been made since the last inspection.

People and staff told us the management were approachable.