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Imagine Act and Succeed Good

Inspection Summary

Overall summary & rating


Updated 10 November 2017

This inspection took place on the 19 and 20 September 2017. We gave the service 24 hours’ notice of the inspection to ensure that the managers were available to speak with us. This was the first inspection of Imagine Act and Succeed since it had been re-registered with the Care Quality Commission in June 2016. The re-registration had taken place due to a change in the office address for the service. The service, under its previous registration as IAS 65 Chorley Road, was inspected in May 2015 and was rated good overall.

Imagine Act and Succeed (IAS) is registered to provide personal care in people’s own homes. The service supports 55 people through their domiciliary care service, 22 people in an extra care scheme (Fiona Gardens) and 21 people lived in supported living properties, either on their own or sharing with others. The domiciliary care service provided support from one visit per week to multiple visits each day. The extra care scheme provided assessed support for 22 people and an emergency on call service for the remaining 50 flats in the scheme. Some of the supported living houses provided 24 hour support and others a planned schedule of support, depending on the assessed need.

The service had a registered manager in place. 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.

All the people who used the service and their relatives were complimentary about IAS and the support provided. The staff said they enjoyed working for the service and felt very well supported by their service leaders and senior managers.

There were sufficient staff on the rotas to meet people’s needs. In the domiciliary care service people said they were supported by regular staff, who were on time and did not miss visits. Relatives said the supported living staff teams were kept as stable and consistent as possible. This meant people were supported by staff who knew them and their support needs well. We were told there was good communication between the staff and people’s relatives.

Detailed person centred care plans and risk assessments were in place. These provided guidance and information about people’s support needs, their likes, dislikes and preferences and how to mitigate the identified risks. Comprehensive positive behaviour support plans were in place for those people with complex behaviours which may challenge the service.

Each person had a one page profile in place documenting key likes, dislikes and how they wanted to be supported.

A living well document was being introduced, part of which documented people’s wishes for their end of life care and support. Some people had completed this; however others did not want to discuss the end of their lives. People living at Fiona Gardens were supported to stay in their flat at the end of their lives if possible. Additional visits were made as their needs changed.

People and their families were involved in writing and reviewing the care plans and risk assessments. Relatives said they had regular feedback from the staff teams about their loved ones.

People received their medicines as prescribed. A medicines lead role and a new medicines system (called Bio-dose) had been introduced at Fiona Gardens in response to a series of medication errors. This had resulted in a large reduction in the medication errors made. We have made a recommendation that all medicines leads are made aware of the full prescribing instructions for the medicines they administer.

Guidelines for when ‘as required’ medicines were to be administered were in place in the supported living service. At the time of our inspection all the people supported at Fiona Gardens were able to tell staff if they needed an ‘as required’ medicine. We discuss

Inspection areas



Updated 10 November 2017

The service was safe.

Risks were identified and clear guidance for staff to follow was recorded to mitigate and manage the risks.

Safeguarding concerns, incidents and accidents were reported and thoroughly investigated. IAS showed they used the investigations to make any changes and improvements that had been identified.

People received their medicines as prescribed and medicines were safely managed. We have made a recommendation for all staff to know the full prescribing instructions for each medicine they administer.

Sufficient staff were available to meet people�s assessed needs. A robust recruitment process was in place.



Updated 10 November 2017

The service was effective.

The service was working within the principles of the Mental Capacity Act (2005). Decision making tools were in place, where required, to guide staff on how they should support people to make their own decisions.

Staff received the training and professional support through job consultations and team meetings to effectively undertake their role.

People were supported to meet their nutritional needs and maintain their health.



Updated 10 November 2017

The service was caring.

People and their relatives were involved in developing and reviewing their care plans.

People said the staff were kind and caring. Staff knew people�s likes, dislikes and support needs.

Staff knew how to maintain people�s dignity and privacy when providing personal care and prompted people to complete tasks independently.



Updated 10 November 2017

The service was responsive.

Detailed person centred care plans were in place that provided guidance for staff in how to meet people�s needs.

A programme of regular activities for people to take part in had recently been established. People were supported to access leisure opportunities in their local community.

The service had a complaints procedure in place. All complaints received had been responded to appropriately.



Updated 10 November 2017

The service was well led.

A robust quality assurance system was in place to monitor the service. New quality auditing measures were being introduced to involve people and their relatives.

Staff said they enjoyed working at the service and felt the management team were very supportive and approachable.

IAS invited feedback about the service from people and their relatives through tenants meetings, family and friends meetings and surveys. Staff were involved in development forums and staff meetings.