Surrey

Updated 17 March 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 Care Act 2014.

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.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was announced and took place on 16 February 2022. The service was given 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.

What we did before the inspection

We reviewed all the information we had received about the service since the last inspection. 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. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

We spoke in person with the registered manager. We contacted four people and their relatives, four staff and one health care professional, to get their experience and views about the care provided. We reviewed a range of records. This included two people’s care and medicine records. We looked at four staff files in relation to recruitment, training and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We requested additional evidence to be sent to us after our inspection. This included training information, and audits. We received the information which was used as part of our inspection.

Updated 17 March 2022

About the service

Surrey is a domiciliary care agency providing care and support to nine people living in their own homes. At the time of the inspection nine people using the service were receiving personal care. Not everyone who used the service received personal care. The Care Quality Commission (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

At the last inspection the agency did not always provide a service that was safe for people to use and staff to work in. This was because recruitment procedures were not robust, and we were not assured that staff were recruited in a safe way to keep people as safe as possible. Staff files were not fully completed and were missing some pre-employment key documents.

At this inspection staff files were fully completed including pre-employment key documents.

The agency provided a safe service for people to use and staff to work in with sufficient staff to meet people’s needs and support them appropriately. This meant people could live in a safe way and enjoy their lives. There were enough staff who were appropriately recruited with required checks carried out. People using the service and staff had risks to them assessed, monitored and updated as required. The agency reported, investigated and recorded accidents, incidents and safeguarding concerns. Medicines were safely administered. The agency met shielding and social distancing rules, used Personal Protection Equipment (PPE) safely and effectively and the infection prevention and control policy was up to date.

The agency culture was open, honest and positive with transparent management and leadership. The statement of purpose clearly defined the agency vision and values, that staff understood and followed. Staff were aware of their responsibilities and accountability and they were willing to take responsibility and report any concerns they may have. Service quality was regularly reviewed, and changes made to improve the care and support people received. This was in a way that best suited people. The agency had well-established working partnerships that promoted people’s needs being met outside its remit to reduce social isolation. Registration requirements were met.

Rating at last inspection

The last rating for this service was requires improvement (published 20 August 2019) and there was one breach of regulation. The agency completed an action plan after the last inspection to show what they would do to improve and by when. At this inspection we found improvements had been made and the agency was no longer in breach of regulations.

Why we inspected

We undertook this focused inspection to check the agency had followed their action plan and to confirm they now met legal requirements. At the last inspection staff recruitment files were incomplete. A decision was made for us to inspect and examine the risks associated with this issue.

CQC has introduced focused/targeted inspections to follow up on previous breaches and to check specific concerns. We undertook a focused inspection approach to review the key questions of Safe, Effective and Well-led where we had specific outlined above.

As no concerns were identified in relation to the key questions is the service Effective, Caring and Responsive, we decided not to inspect them. Ratings from the previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 Surrey 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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk