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Number 12 Chapeltown Enterprise Centre Good


Inspection carried out on 11 April 2019

During a routine inspection

About the service

Number 12 Chapeltown Enterprise Centre is a domiciliary care agency and provides care and support to people living in their own homes. Not everyone using the service receives 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, medicines and eating. Where they do, we also take into account any wider social care provided. At the time of our inspection 49 people received the regulated activity ‘personal care’.

People’s experience of using this service and what we found

People were kept safe from risk of abuse and avoidable harm. Accidents and incidents were analysed by the registered manager and learning was shared with staff to prevent reoccurrence. The provider employed enough, suitably skilled staff to care for people safely.

Staff worked effectively together to meet people’s needs. 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 recognised and valued the diversity of people using the service. People were cared for as individuals and received kind and compassionate support. Staff supported people to remain as independent as possible.

People received person-centred care and treatment that was appropriate to their needs and preferences. Information was provided to people in a way they understood and enabled them to make informed decisions about their care.

The service benefitted from a registered manager who worked collaboratively with staff to deliver high quality care.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

At the last inspection the service was rated requires improvement (published 16 April 2018). Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider is no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Inspection carried out on 1 February 2018

During a routine inspection

Number 12 Chapeltown Enterprise Centre is a domiciliary care agency. It provides personal care to people living in their own houses and flats. It provides a service to older adults and younger disabled adults. The service supports people in Leeds and surrounding areas, such as North Yorkshire. At the time of the inspection there were eight people using the service.

This announced inspection took place on 1, 5 and 12 February 2018. We gave the provider 48 hours' notice because it was a small service and we needed to make sure someone would be at the office. This was the first inspection since the service was registered in July 2016.

There was 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.

Quality assurance systems and processes, that included audits, were not sufficiently robust to maintain standards and drive improvements for everybody. People told us it was it was difficult to get hold of a manager if they wanted to speak with someone.

People knew how to make a complaint and had opportunities to feedback their views at reviews. However, there had been no recent formal survey to find out people's satisfaction with the service.

The systems in place to make sure that people were supported to take medicines safely required improvement. Medicine records were maintained but had not been used consistently. Auditing processes had not identified areas of medicines practice that required improvement.

Recruitment records showed that there were gaps in references for new staff. This meant the provider could not be certain they had the required skills and were of suitable character and background to work in the care sector.

The manager and staff were aware of the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People were offered choice. Care staff sought consent before supporting with personal care.

People were treated with dignity and respect by the care staff who supported them. Care plans were in place for each person who used the service. These contained detailed information about people's individual preferences and how staff should provide person centred care.

People were supported to maintain their health and had access to health services if needed.

Risks to people in relation to their needs had been assessed. Staff were confident about how to protect people from harm and what they would do if they had any safeguarding concerns.

Care staff were trained in infection control practices. They were provided with protective equipment such as gloves and aprons to use as required.

There were sufficient numbers of staff to make sure people’s needs were met. Staff told us they were supported in their roles and could meet a manager to discuss any issues.

People’s needs were reviewed and appropriate changes were made to the support people received if required. Risk assessments contained clear information about how risks should be minimised.

We identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely 'Good governance'. You can see what action we told the provider to take at the back of the full version of the report.

This is the first time the service has been rated 'Requires Improvement'.