We carried out a review of the data available to us about Sahan Cares C.I.C on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Sahan Cares C.I.C, you can give feedback on this service.
Sahan Cares C.I.C is a domiciliary care agency providing personal care and support to people living in their own homes in the London Borough of Hillingdon. The organisation is a family run business, and this is their only location. They operate a social enterprise offering employment to refugee women within the local community.
Not everyone who used the service received 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. At the time of the inspection, 68 people were receiving personal care support.
People’s experience of using this service and what we found
People using the service and their families were happy with the care they received. They told us they had been involved in planning their care and were able to make choices. They said the staff respected them and treated them with kindness. They had good relationships with the staff.
The staff were well supported. They had the training and information they needed to care for people safely and well.
People received their medicines safely and as prescribed.
People's care was appropriately planned, and their needs were met in a personalised way. The provider had assessed and planned for risks to their safety and wellbeing.
There were effective systems for monitoring and improving the quality of the service, which included responding to and learning from complaints, incidents, accidents and safeguarding alerts. There were regular audits and analysis of the service. The staff were well informed through team meetings. Staff were supported to develop new skills.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 5 August 2021)
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an announced comprehensive inspection of this service on 31 March 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sahan Cares C.I.C on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Sahan Cares C.I.C. is a domiciliary care service for people living in their own homes in the community. At the time of our inspection, there were 81 people using the service.
Not everyone who used the service received 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
During the inspection we reviewed the provider’s safeguarding investigations and found not all of these were completed. Notifications the provider was required to send to CQC were not always submitted in a timely manner.
Risk assessments were not always detailed enough to provide staff with guidance for safe care or implemented effectively to help reduce risks to people. Care plans did not always provide relevant information. For example, end of life wishes.
The provider had systems in place to monitor, manage and improve service delivery to people, but these were not always effective and did not always identify issues raised at the inspection.
We recommended the provider follow national guidance around medicines, infection prevention and control and recording people’s preferences.
Safe recruitment procedures were followed, and staff were supported through induction, training and supervision. Staff followed appropriate infection prevention and control practices.
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.
There was a complaints procedure in place and the provider knew how to respond to complaints.
People, relatives and staff reported the care manager was available and responsive.
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 25 April 2018).
Why we inspected
This was a planned inspection based on the previous rating.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.
Enforcement
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 identified breaches of regulation in relation to safe care and treatment and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Sahan Cares C.I.C provides a domiciliary care service for adults with a range of needs. The service offers support to people who require help with day to day care and support including personal care, meal preparation, light housework, shopping, outreach services and companionship. At the time of our inspection there were 81 people receiving personal care.
At the last inspection, the service was rated Good. At this inspection we found the service remained Good.
People said they felt safe using the service and staff knew the action to take to safeguard people from the risk of abuse. Recruitment procedures were in place and being followed to ensure only suitable staff were employed. There were enough staff to meet people’s needs. Risks were assessed and identified so action could be taken to minimise them. Infection control procedures were being followed. Staff knew how to support people with their medicines so that they received them safely. The provider was open to learning from events to improve practice.
People’s needs were assessed and care was planned to meet their care and support needs. Staff completed a recognised induction training in health and social care and received ongoing training, to gain the skills and knowledge to care for people effectively. Where required people were supported with their dietary needs and with accessing healthcare services. 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.
People were happy with the care and support they received and found the staff to be very caring. Staff understood people’s individual care and support needs and worked with them to meet these. Staff were kind and respectful and maintained people’s privacy and dignity. Religious and cultural needs were identified and staff understood people’s needs and wishes and respected them.
Care records were comprehensive and provided a good picture of the person and their needs. They were reviewed periodically, and whenever a person’s needs changed, to keep the information up to date. People were given copies of the complaints procedure and were confident to raise any issues, which the provider addressed promptly.
The provider had relevant qualifications and experience and ran the service effectively. Monitoring processes were in place and followed. The provider strived to continually improve the service provision. They followed legislation and good practice guidance and listened to people and staff to gain feedback about the service and planned and implemented improvements.
Further information is in the detailed findings below.
Sahan Cares C.I.C provides a domiciliary care service for adults with a range of needs. The service offers support to people who require help with day to day routines including personal care, meal preparation, light housework, shopping and companionship. At the time of our inspection there were 68 people receiving personal care.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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.
We received positive feedback from people, relatives and care staff who felt the service was well run and people’s needs were identified and being well met.
People felt safe using the service and systems were in place to identify and manage risks. Staff understood how to support people with medicines management so they received their medicines safely. Infection control procedures were in place and being followed by staff to minimise any risks.
Staff recruitment procedures were in place and were being followed to ensure only suitable staff were employed at the service. There were appropriate numbers of staff available to provide the care and support each person required.
Staff understood safeguarding and whistleblowing procedures and the process to follow to report any concerns. There was a complaints procedure in place and people confirmed they would be confident to raise any issues they might have, so these could be addressed.
Staff had received training and demonstrated an understanding of people’s individual needs and choices and how to meet them. Staff understood the importance of treating people with dignity and respect and people and relatives confirmed this.
We found the service met the requirements of the Mental Capacity Act 2005 (MCA). The registered manager and the staff understood their responsibilities in line with the MCA requirements and knew to report any concerns in relation to these that might arise. The registered manager confirmed no person was being deprived of their liberty at the time of our inspection.
People received the support they required to meet their nutritional needs. Systems were in place to respond to people’s healthcare needs and staff understood these.
Staff understood the importance of meeting people’s individual needs and provided person-centred care and support to people. Care records identified people’s needs and the ongoing care and support people required and received.
The registered manager was supportive and approachable. They championed the importance of the different religious and cultural needs of people and care staff to be understood and respected.
Systems were in place to monitor the service and the registered manager kept up to date with current good care practices and procedures to maintain a good standard of care provision.
The provider told us that arrangements would be reviewed and action would be taken to ensure compliance by 29 November 2013.
During this inspection we found that the provider had addressed shortfalls identified with the recruitment procedures.
People said they were happy with the care being provided and that the care workers were kind and showed them respect.
People and their relatives told us they would be confident to raise any concerns with the service or with the local authority so they could be addressed.
Staff had received training prior to starting to care for people and further training was planned, to keep staffs knowledge and skills up to date.
Recruitment procedures were in place but were not being always followed in that some gaps in information had not been fully explored, and this could place people at risk.
Systems were in place for monitoring the quality of care being provided and for learning from incidents so action could be taken to minimise the risk of reoccurrence.
Comments we received from people using the service included, 'they are very respectful and do everything you need', 'they look after me really well' and 'I am very happy with the service at this time'.
People were assessed prior to receiving care so their needs were identified and care could be planned to meet them. People's choices regarding their religious and cultural needs were identified and staff were aware of the importance of treating people with respect and caring for them as individuals.
Safeguarding and whistle blowing policies were in place and were being followed, so people were being protected from the risk of abuse. Complaints procedures were in place and the manager encouraged people to express any concerns so they could be addressed promptly.
Staff were available to attend to people and meet their needs. Staff had received training to provide them with the skills and knowledge to care for people effectively.
The majority of people were matched with staff who could communicate with them in their first language. Where this was not possible, staff identified other methods such as using signals and gestures to communicate with people. One relative described the staff as 'brilliant' and both relatives were satisfied with the care being provided.