180 Surrey Street

Updated 19 May 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

The inspection was completed by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

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, they were also the provider.

Notice of inspection

We gave the service 24 hours notice of the inspection. This was because the service is small and we wanted to make sure the management team were available. On the day of the inspection the registered manager was not available, however, we had contact with them post the inspection site visit.

Inspection activity started on 19 April 2022 and ended on 20 April 2022. We visited the office location on 20 April 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We reviewed a range of records including the relevant sections of four people’s care records and medicines records. We looked at four staff files in relation to recruitment, supervision, spot checks and training. We reviewed other records related to the management of the service, including the provider’s policies. We spoke the office manager.

What we did after the inspection

We spoke with five care staff and the registered manager.

We continued to seek clarification from the provider to validate evidence found.

Updated 19 May 2022

About the service

180 Surrey Street is a domiciliary care service. It provides care for people living in their own houses and flats. 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. At the time of our inspection, 16 people were receiving personal care.

People’s experience of using this service and what we found

Risk assessments in relation to people’s care needs were inconsistently detailed and had not been reviewed at the frequency the provider had identified as required. Medicine administration records had not been audited regularly as per the provider’s audit process and records reviewed showed there were missing staff signatures.

Care calls were not effectively monitored, and shortfalls were identified in how care calls had been provided.

The complaints log had not been kept up to date. However, people told us they knew how to make a complaint and complaints, or concerns had been acted upon by the management team.

We received a mixed response about people’s experience of being advised if care staff were running late. Some people told us they were informed and others not.

Staff had received training on infection prevention and control and wore personal protective equipment. Some people raised concerns that staff did not always wear masks or wore them correctly. This was shared with the registered manager who agreed to follow up with staff.

There were sufficient staff available, however, the registered manager and office manager covered staff shortfalls, and this impacted on the monitoring of care calls. Staff were overall recruited safely and received an induction, training and ongoing support.

Overall, people were positive about the staff competency and approach to care. Positive feedback was received about the management team and support.

Staff spoke positively about working for the provider and felt well supported, valued, and listened to. Staff received ongoing training and opportunities to discuss their work.

Staff were aware of their responsibilities to protect people from abuse and avoidable harm. People felt they received safe care and support. The provider had systems and processes to manage incidents and incident records were reviewed for any learning opportunities.

People were involved in decisions about their care. Review meetings had been conducted and spot checks completed to check staff’s competency and to gain feedback from people who used the service.

Staff worked with external professionals to support people’s needs and outcomes.

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 Good (published 3 April 2019).

Why we inspected

We received concerns in relation to the quality and safety of care provided.

As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements.

Please see the Safe and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 180 Surrey Street on our website at www.cqc.org.uk.

Enforcement

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 a breach in relation to governance of the service at this inspection.

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 work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.