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SD Care Agency Requires improvement

This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 February 2018

This inspection took place over three days. We carried out our inspection to the offices of the service on 16 November 2017 which was announced. We gave 48 hours’ notice of the inspection to ensure that staff would be available in the office. This is our methodology for inspecting domiciliary care agencies. Following that we carried out telephone interviews with staff on 20 and 22 November 2017.

SD Care Agency is registered to provide personal care needs of older people who may have dementia, physical disabilities and sensory impairments. At the time of our inspection the service was providing personal care to 44 people.

A registered manager was in post. 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.

Systems and procedures to safeguard people from abuse were not being followed by the registered manager. They had failed to notify the local authority and the Care Quality Commission (CQC) about four safeguarding concerns that had been reported to them.

People were not receiving the care in the way they preferred it. Staff had not visited at the times specified which caused concern to people. When staff were on annual leave, new staff allocated were not introduced which caused anxiety to people.

Contemporaneous records were not always maintained for each person and actions identified when carrying out performance reviews on staff were not recorded.

Quality assurance systems were in place but not all were robust. The issues we had identified during the inspection had not been noted through the quality assurance systems. People, relatives and associated professionals were able to provide regular feedback through completing questionnaires. Comments were positive about the care provided to people.

People and their relatives told us that they felt safe with staff who attended to their needs. Staff who visited people had a good understanding of the different types of abuse and the procedures to be followed if they had witnessed or suspected abuse had taken place. Robust recruitment processes were followed to help ensure that only suitable people were employed at the agency. People received the medicines they required. Infection control procedures were in place that helped staff to protect people against the risk of cross infection.

People were supported by staff to ensure their needs were met when they arrived. There was a system in place to protect people from potential risks and staff had a good understanding of how to manage identified risks. Care plans were in place for people and included information about how people preferred to be supported.

Accidents and incidents were recorded and monitored by the registered manager. These were discussed with staff to help minimise the risk of a repeated event. If an emergency occurred at the office or there were adverse weather conditions, people’s care would not be interrupted as there were procedures in place which were known by staff. Emergency out of hour’s contact details were provided to people in the Service User Guide and in their care records.

People were supported by staff who received training, supervisions and annual appraisals that helped them to meet people’s needs. They also received spot checks to ensure they supported people effectively. New staff commencing their duties undertook induction training to help prepare them for their role.

Staff were up to date with current guidance to enable people to make decisions. Staff had a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) as well as their responsibilities in respect of this.

People prepared and cooked their own meals for staff to heat in the microwave. Meals taken by people were recorded in care records. Staff alerted people’s relatives where concerns had been identified and healthcare professionals were involved as and when required.

People were supported by staff to remain as independent as they were able. People were encouraged to complete daily tasks such as washing and dressing. People told us that staff showed kindness and their privacy and dignity were respected by all staff who attended to them.

People were protected because a complaints procedure was available for any concerns they had. All people had been provided with a copy of this document. Complaints received by the provider had been investigated and resolved within timescales set in the policy.

Staff informed us that they felt supported by the registered manager who had an open door policy and were approachable. Staff meetings took place and staff received regular contact from their line manager and the registered manager.

The provider had a set of aims and objectives that included respecting and encouraging the rights of individual people, supporting individual choice and respecting the individual requirements for privacy.

During our inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made one recommendation to the registered provider. You can see what action we told the provider to take at the back of the full version of the report.

Inspection areas


Requires improvement

Updated 8 February 2018

The service was not consistently safe.

People may not always be safe from harm. The registered manager and provider had not understood their safeguarding responsibilities in regards to following the reporting procedures when abuse or suspected abuse had been identified.

People received the medicines they required.

People were cared for by a sufficient number of staff who had gone through a formal recruitment process before commencing work.

People were kept free from infection because staff understood the infection control processes to prevent cross infection.

Where accidents and incidents had occurred staff took action to help ensure these did not reoccur.



Updated 8 February 2018

The service was effective.

Staff received appropriate training and had opportunities to meet with their line manager regularly.

Staff had an understanding of the Mental Capacity Act (MCA) and their responsibilities in respect of this.

People were supported with their health and dietary needs. When a risk had been identified appropriate risk assessments had been produced to monitor the risk posed.


Requires improvement

Updated 8 February 2018

The service was not consistently caring.

People’s preferences in relation to the timing of their visits were not always being adhered to.

Staff showed people respect and made them feel that they mattered.

Staff were caring and kind to people.

People were supported to remain independent and make their own decisions.



Updated 8 February 2018

The service was responsive to people's needs.

Staff responded well to people’s needs or changing needs and care plans were in place for each person.

Information about how to make a complaint was available for people and their relatives.


Requires improvement

Updated 8 February 2018

The service was not consistently well-led.

The registered manager was not aware of their statutory requirements and duties in relation to reporting incidents to the CQC.

Quality audits were not fully robust and outcomes of some audits taking place were not written down.

The registered manager promoted a positive culture within the staff team and staff felt supported by her.

There were systems in place to monitor the quality of the care that people received.

People’s views about the running of the agency were sought and the provider showed a commitment to improve the service for people.