12 February 2019
During a routine inspection
People’s experience of using this service: The service did not have a robust auditing system in place. Audits that were completed lacked detail and were not completed regularly.
The service did not have a clear or accurate oversight of safeguarding incidents. However, people we spoke with told us that they felt safe and staff were able to tell us how they would respond if they suspected abuse.
Risks were not consistently assessed and risk assessments were not always updated when something changed. This meant that records may not include details of the most recent level and types of risk. However, people told us that they felt the care they received was safe.
No evidence of capacity assessments or best interests was available at the time of the inspection. However, one person was assessed as lacking capacity to make some decisions and relevant assessments had not been completed. The record included details of how the person may be assisted to make their own decisions. This meant that although records were not complete, people were being supported to make their own decisions rather than decisions being made for them.
Although people had experienced missed visits, there was no effective system to monitor these so that causes could be identified and actions taken to prevent recurrence.
People told us that the service responded to their needs and that visits could be changed informally by ringing the office.
People spoke positively about the registered manager and management team. People told us that they could approach the registered manager and care staff with concerns or complaints when necessary,
People told us that they received care from staff who were kind and that care visits were completed by staff that they knew.
For more details, please see the full report which is on CQC website at www.cqc.org.uk
Rating at last inspection: Requires Improvement (March 2018).
Why we inspected: This was a planned inspection based on the previous rating.
Enforcement: We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Follow up: We will review the report on actions the provider intends to take following the inspection. We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.