Background to this inspection
Updated
15 December 2022
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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
Inspection team
The inspection team consisted of two inspectors and two Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
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 (CQC) 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.
The service did not have a manager registered with the CQC. There were arrangements for the manager to be registered with CQC.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because we needed to be sure that the provider or the manager would be in the office to support the inspection. We visited the office location on 26 August 2022.
What we did before the inspection
Prior to the inspection we reviewed information and evidence we already held about this service, which had been collected via our ongoing monitoring of care services. This included notifications sent to us by the service. Notifications are changes, events or incidents that the provider is legally obliged to send to us without delay. This information helps support our inspections.
During the inspection
We spoke with 17 relatives of people who used the service to help us understand the experience of people who could not speak with us. We also spoke with nine people using the service. Some people we spoke with had limited mobility and required support with transfers. We spoke with the manager, two service directors, care coordinator and seven care workers. We reviewed the care records of seven people using the service, personnel files of seven care workers and other records about the management of the service.
Updated
15 December 2022
About the service
Bluebird Care (Brent) is a domiciliary care service which provides personal care and support to people in their own homes. At the time of the inspection there were 127 people using the service, of which 91 were receiving 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
We have made one recommendation regarding accessible communication.
Moving and handling assessments lacked some detail and could be further developed. The assessments did not include the sling size, when the hoist was last serviced, hoist type, or what checks needed to be completed to ensure the sling was fit for purpose.
The provider did not have an effective system for reviewing lessons learned from incident investigation. For example, two recent falls incidents had not prompted action to prevent a recurrence of similar incidents.
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.
People were protected from the risk of harm and abuse. There were effective systems and processes in place to minimise risks. Care workers had been recruited safely and they knew how to identify and report concerns.
People received person centred care. Their assessments showed they had been involved in the assessment process.
Care workers were knowledgeable about people’s needs. They had completed essential training and we saw from records they were up to date with it.
People were protected from the risks associated with poor infection control because the service had processes in place to reduce the risk of infection and cross contamination.
There were governance structures and systems which were regularly reviewed. There was a complaints procedure in place, which people’s and their relatives were aware of.
Quality assurance processes such as audits and spot checks were in place.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 13 May 2019).
Why we inspected
The inspection was prompted in part by notifications of two incidents following which two people using the service sustained serious injuries. The incidents are subject to initial inquiries to determine whether to commence a criminal investigation. As a result, this inspection did not examine the circumstances of the incidents. However, the information shared with CQC about the incidents indicated potential concerns about the management of risk of falls from moving and handling equipment. This inspection examined 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 are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to risk assessments and a lack of an effective quality assurance system.
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.