Felicity Care

Updated 19 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by one inspector.

Service and service type

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 29 April 2022 and ended on 23 June 2022. We visited the location’s office on 29 April 2022. We spoke with one relative on 21 June 2022, with one person on 23 June 2022 and staff on 17 June 2022 to gain their feedback. Inspection feedback was given to the registered manager on 20 June 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and formal

notifications that the service had sent to the CQC. Notifications are information that registered persons are required to tell us about by law that may affect people's health and wellbeing. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

During the office visit, we spoke with the registered manager and reviewed some policies, quality assurance records, accident and incident records and complaints.

After the inspection continued to seek clarification from the provider to validate evidence found. We looked at one person’s care plan and medicine administration records, four staff recruitment files, policies and procedures, quality assurance records and training information. We spoke the relative of the person using the service, four care staff and one healthcare professional.

Updated 19 July 2022

About the service

Felicity Care is a domiciliary care agency providing the regulated activity of personal care to people living in their own homes. At the time of our inspection there was one person 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

One relative told us that the care staff that supported their family member were kind and caring. However, despite this feedback we identified areas of concern similar to those from the previous inspection which had not been addressed.

Specific management policies and procedures in place were not reflective of best practice and current guidelines and lacked guidance on the processes to be adhered to ensure regulations were being met. The lack of management audits and checks meant that the issues we identified during this inspection had not been identified by the registered manager.

Staff recruitment processes had not been robustly completed and verified to ensure that staff employed were safe to work with vulnerable adults.

People received their medicines safely and as prescribed. Risks associated with people’s health and care needs had been assessed and guidance was available to staff on how to manage risk to keep people safe.

Staff were aware of their responsibilities to raise concerns if they felt a person was being abused. The service understood the importance of infection prevention and control and had measures in place to keep people safe.

Staff felt supported in their roles. The service worked in partnership with other organisations to support people and their relatives

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 8 April 2021). The service remains rated requires improvement. We identified issues relating to unsafe recruitment practices of staff and the governance of the service. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We carried out an announced focused inspection of this service on 16 December 2020. At the inspection we recommended that the provider consider current guidance on the management of medicines and that they consider training and guidance around maintaining appropriate and accurate care records.

We undertook this focused inspection as the provider had told us that they had made the required improvements and requested a review of their ratings as the current rating was impacting their ability to take on more work. During this inspection we found that whilst some improvements related to the recommendations made had been implemented, we identified further issues relating to recruitment of staff and good governance. This report only covers our findings in relation to the key questions of Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the previous comprehensive inspection to calculate the overall rating. The overall rating for the service has remained as requires improvement. 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 Felicity Care on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to regulations 19; fit and proper persons employed and 17; good governance. 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 from the provider to understand what they will do to improve the standards of quality and safety. We will also meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will continue to monitor information we receive about the service, which will help inform when we next inspect.