We carried out a review of the data available to us about Emmaculate Care Services Selby Office 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 Emmaculate Care Services Selby Office, you can give feedback on this service.
Not everyone using Emmaculate Care Services Selby Office receives 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.
Inspection activity started on 14 June 2018 and ended on 27 June 2018. It included telephone calls to people who used the service and their relatives or carers. We visited the office location on 18 and 27 June 2018 to see the registered manager and office staff; and to review care records and policies and procedures. The provider was given five days’ notice of our inspection, because the location provides a domiciliary care service and we needed to be sure that someone would be in the location’s office when we visited. At the time of our inspection, there were 19 mainly older people using the service.
At the last inspection in April 2017, records were not always well maintained and effective systems were not in place to monitor and audit the quality and safety of the service. We rated the service requires improvement overall and identified one breach of regulation relating to the governance of the service. We asked the provider to take action to address our concerns. At this inspection, improvements had been made and we rated the service ‘Good’ overall.
Risk assessments did not always contain clear and detailed information about how staff should manage risks to keep people safe. It is important that risk assessments provide clear and detailed information to support staff to provide consistently safe care.
Staff supported people to take their prescribed medicines. The provider had not followed their own policy and procedure, as sufficiently detailed protocols were not always in place to guide staff on when to administer medicines prescribed to be taken 'as required', such as pain relief. It is important staff have information about when to administer these medicines to ensure they are given safely and appropriately.
Improvements had been made to how staff training, supervision and appraisals were evidenced. Staff completed a range of training courses to support them to provide effective care. The registered manager documented observations and competency checks to monitor the support they provided and support staff to continually improve and develop. Staff received regular supervision and an appraisal of their performance. People gave positive feedback about the skills and experience of the staff who supported them.
Consent to care was recorded. Staff documented mental capacity assessments. We spoke with the registered manager about making sure they recorded the specific decision for which people’s mental capacity was being assessed. Staff supported people to make sure people ate and drank enough. They helped people to access healthcare services if they were unwell or needed medical attention.
Staff were trained to recognise and respond to safeguarding concerns. The provider safely recruited new staff. Enough staff were deployed to meet people’s needs. People told us staff were reliable and punctual. Systems were in place to minimise the risk of spreading infections.
People praised the attitude and friendliness of staff and complimented their kind, caring and respectful approach. People told us staff listened to them, treated them with dignity and respected their decisions.
Staff provided person-centred care and responded to people’s needs. People told us they felt able to raise issues or concerns and confident management would respond and act on their feedback.
The service had a registered manager. They had been the registered manager since October 2016. A registered manager is a person who has registered with the 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. The registered manager was supported by a business manager, deputy manager, care coordinators, a field supervisor and quality monitoring lead in the management of the service.
People who used the service and relatives gave overwhelmingly positive feedback about the quality of the care and support provided. Staff told us management were approachable and supportive. We made a recommendation about continuing to develop audits to monitor all aspects of the service.
The service is registered to support people with a wide range of needs, but at the time or our inspection predominantly supported older people and people who may be living with dementia. The service supported people who lived in and around Selby.
We inspected this service on 29 March and 12 April 2017. This was our first inspection of this service since it was newly registered in October 2016. The inspection was announced. The registered provider was given 24 hours’ notice of our visit, because the location provides a domiciliary care service and we needed to be sure that someone would be in the location’s office when we visited. At the time of our inspection, there were 16 people using the service.
This inspection was in part prompted by concerns shared with us by North Yorkshire Police about the registered provider’s recruitment practices. We explored these concerns with the Police during the course of our inspection and found that the registered provider was completing appropriate recruitment checks.
The registered provider is required to have a registered manager as a condition of registration for this service. 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. On the day of our inspection, there was a registered manager in post and as such the registered provider was meeting this condition of their registration. The registered manager was also the registered provider’s nominated individual.
At this inspection, we found that records were not always well maintained. We found gaps in staff training records, evidence of recorded supervisions and that capacity assessments were not documented. Medication audits and audits of care plans were not robust or regularly completed.
This was a breach of regulation relating to the governance of the service. You can see what action we told the registered provider to take at the back of the full version of this report.
Staff supported people who used the service to take prescribed medicines. Staff received training; however, the registered provider did not document competency assessments to check and evidence that staff had the skills needed to safely administer medicines. We have made a recommendation about this in the body of our report.
We found that sufficient staff were employed to meet people’s needs. People who used the service told us they felt safe with the care and support staff provided. There were systems in place to support staff to recognise and respond to safeguarding concerns.
Rotas were organised to ensure people were visited by a small group of staff. This supported people who used the service to develop positive caring relationships with staff. People who used the service told us staff were kind, caring and treated them with dignity and respect.
People who used the service provided feedback about the skills and knowledge of staff. Staff told us they felt supported by the registered manager and business manager. Care plans and risk assessments contained information to support staff to meet people’s needs. People were supported to ensure they ate and drank enough and to maintain their health and wellbeing.
People who used the service knew how to complain and there were systems in place to manage and respond to complaints.