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Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 December 2018

This comprehensive announced inspection took place on 19 and 24 October, 1 and 6 November 2018.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults and younger disabled adults. Not everyone using the service received a regulated activity; the Care Quality Commission (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 take into account any wider social care provided.

Service provision was in the Leeds and Durham area at the time of the inspection. There were eight people using the service.

At the last inspection in August 2017 we rated the service as Requires Improvement. At that inspection we found the provider was in breach of Regulation 12, Safe care and treatment, Regulation 17, Good governance and Regulation 18, Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the provider did not have systems for the proper and safe management of medicines and they were not doing all that was reasonably practicable to militate against risk. We saw systems in place to manage, monitor and improve the quality of the service provided were not effective. We also found suitably competent staff were not consistently provided to meet people’s care and support needs and staff were not always provided with appropriate support and training to enable them to carry out the duties they were employed to perform.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions in all the domains to at least Good. During this inspection, we saw some improvements had been made. However, continued work was required to ensure the provider was meeting all regulations.

The provider had improved their arrangements for managing people's medicines but needed to make sure the records were accurate at all times. Risk management plans were in place and had improved. They described the risks people faced and the actions needed to keep people safe.

The provider had improved the support given to staff but still needed to develop this further to make sure there was a consistent approach to training and to ensure supervision was recorded. Training records did not indicate what the provider considered mandatory training for staff or the expected interval between refresher training. Staff training records showed some staff had not completed some training courses such as infection prevention and control, food hygiene and the Mental Capacity Act. Staff told us they felt well-supported and had regular contact with the provider. However, this support was not always recorded which meant we could not be sure staff received supervision in line with the provider’s policy.

We have made a recommendation about the on-going the management and recording of staff training and support.

The provider had introduced audits for monitoring quality and safety, however, these were basic and did not always drive improvement. Systems and processes around governance and records needed to improve further. Audits of medicines had not identified the issues with records that we found. No formal audits of training and staff support were in place to check staff’s training equipped them for their role. Care records audits had not identified a person who used the service did not have a completed care plan in place. No records of checks on staff’s performance were made when they completed shadowing (working alongside an experienced staff member) or when spot checks were carried out by the registered manager.

There was a registered manager in post. A registered manager is a person who has registered with CQC 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.

People told us they felt very safe with staff and the care they were provided with. There were enough staff to support people safely and provide continuity of care for people. People were supported by staff who could communicate in their preferred language and dialect. This was very important to people and their relatives. We found some concerns with the safety of recruitment procedures and the recording of some processes. The registered manager took action to address these concerns during the inspection.

Staff showed a good awareness of safeguarding and making sure people were treated well. Staff understood their role and responsibilities for maintaining good standards of cleanliness and hygiene.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. Staff understood their responsibility to seek people's consent prior to care and support being provided.

People received support from health care professionals where they needed this to keep well. There were good systems in place to ensure staff and the provider worked with health professionals to promote and monitor people’s health needs. Where needed, people who used the service received support from staff to ensure their nutritional needs were met.

People told us they or their family members were treated very well. They said care was delivered in a dignified and respectful manner. Staff were described as kind, caring and patient. They understood people’s cultural needs and were respectful of this.

Staff and the provider showed very good knowledge of the people they supported and understood how to maintain people’s privacy and dignity. It was clear they had developed positive relationships with people and encouraged their independence. Care plans were comprehensive to make sure staff had all the information required to support people as they wished.

Staff felt supported by the management team. People, their relatives and staff all spoke highly about the way the service was managed. People were aware of who to speak to if they had any concerns and told us they felt confident to do so. People told us the provider constantly sought feedback from them on their satisfaction with the service. However, we found this feedback was not always recorded.

We found one breach of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to governance. You can see the action we have told the provider to take at the end of this report.

Inspection areas


Requires improvement

Updated 7 December 2018

The service was not consistently safe.

Medicines records needed to be developed further to make sure safe administration practice was always followed.

We found some concerns with the safety of recruitment procedures and the recording of some processes. Staff understood what abuse was and how to report it.

There had been improvements to the management of risks. Risk management plans were completed with good guidance for staff to follow.


Requires improvement

Updated 7 December 2018

The service was not consistently effective.

Staff told us they received good training and support to carry out their role. However, records showed there were some gaps in staff’s training and the support they received.

People consented to their care and the service operated within the principles of the Mental Capacity Act 2005 to protect people’s rights.

People were supported to maintain their health and wellbeing and their nutritional needs were met.



Updated 7 December 2018

The service was caring.

People were supported by caring staff and their privacy and dignity was respected.

Staff knew people well and good relationships had developed between people and the staff.

People's equality, diversity and human rights needs were met. People could make their own choices and these were respected.



Updated 7 December 2018

The service was responsive.

People who used the service and relatives were involved in decisions about their care and support needs. There was a sensitive approach to the consideration of people’s end of life care.

People were supported by staff to avoid social isolation.

People told us they knew who to speak to if they had any concerns or complaints and were confident they would be listened to.


Requires improvement

Updated 7 December 2018

The service was not consistently well led.

There had been some improvements to the governance systems in the service. Further improvements were required to demonstrate robust oversight and effectiveness of these systems, as they had failed to identify the concerns we found with a number of records within the service.

The registered manager and staff worked in partnership with other services to help ensure people received effective care.

We received positive comments about the registered manager in relation to how supportive they were and their commitment to the service.