We carried out a review of the data available to us about Peripatetic Service De Lacy Gardens 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 Peripatetic Service De Lacy Gardens, you can give feedback on this service.
Peripatetic Service De Lacy Gardens provides personal care to people living in their own flats within an extra care housing development. This consists of one building which contains people’s homes, communal areas such as meeting rooms, hairdresser, shop and a restaurant. The provider and the landlord also have offices in this building. At the time of our inspection there were 21 people who used the service.
There was good support available to people to make decisions about their care. We made one recommendation about improving the records relating to the support one person needed for decisions they could no longer make alone.
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. CQC does not regulate premises used for extra care housing; this inspection looked at people's personal care and support service.
People felt safe using the service, and had care and support provided by sufficient, safely recruited staff. The management of medicines remained safe, and people got these when they needed them.
People were protected from abuse, and any risks associated with their care were well documented with clear guidance for staff to follow.
Staff had a robust induction and received the on-going training and support they needed, including when they supported people at the end of their lives.
People received effective care that helped them maintain healthier lives, and the provider worked well with other health professionals when necessary.
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.
People told us staff were caring and said they were supported to remain as independent as possible. Care plans were written and reviewed with people’s involvement, which helped ensure support was always in line with current needs and respected their preferences. When people made complaints there were good processes in place to ensure issues were addressed.
Care was person-centred, and we did not find any evidence of discrimination in the service. Systems to measure, monitor and improve quality in the service were effective and involved people and staff. The registered manager was meeting the requirements of all legislation covering health and social care.
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 requires improvement (published July 2018). 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
This was a planned inspection based on the previous rating.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Peripatetic Service De Lacy Gardens on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented, and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.
People using the service lived in their own flat in a purpose built complex and had access to care and support 24 hours a day, seven days a week. There was a communal dining area for people to use at lunchtime if they wished.
There was a registered manager in post at the time of inspection. 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.
People’s allergies were not always recorded on the medication administration records (MARs). PRN ‘when required’ protocols were not in place to guide staff as to when these medicines should be given. Systems and processes in place to manage medicines were not always safe or effective. There was no set criteria used for any risk assessments. There was no corresponding risk score used to assess risk therefore it was not clear what people’s level of risk was. We found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
People were supported by sufficient numbers of staff to meet their needs. Staff underwent appropriate checks prior to starting work. Staff received an induction, regular supervision and training. We made a recommendation for the provider to maintain an overview of all staff training to ensure it remained up to date.
The service followed the principles of the Mental Capacity Act.
Staff involved people in making decisions about their care, support and treatment as far as possible. People told us staff understood their needs and treated them with dignity and respect. Staff gave clear examples how they respected people’s privacy and dignity.
The provider had a complaints policy and procedure. People were aware of how to make a complaint. Complaints were responded to appropriately.
Staff were happy working at De Lacy Gardens and felt supported by the management team.
Although the registered manager had begun to develop auditing systems, we found the registered manager and provider did not have a sufficient overview of the service. We concluded the provider did not have appropriate systems and processes for assessing and monitoring the quality of the service. The provider did not have sufficient systems and processes to mitigate the risks relating to the health, safety and welfare of service users.
We found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
You can see what action we told the provider to take at the back of the full version of the report.