Background to this inspection
Updated
28 February 2023
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.
This was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to, Regulation 12 ( Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities), where we found risks associated with peoples care were not always identified and managed. Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities), where we found the provider had not ensured sufficient systems were in place to monitor and improve the quality and safety of the service. Regulation 19 (Fit and Proper Persons Employed) of the Health and Social Care Act 2008 (Regulated Activities), where we found the provider was unable to demonstrate safe recruitment systems were in place, and records regarding staff training, were not sufficiently detailed.
Inspection team
The inspection was carried out by 2 inspectors.
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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was announced. 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 9 January 2023 and ended on 13 January 2023. We visited the location’s office on 11 January 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We used this information to plan our inspection. 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.
During the inspection
During the inspection we spoke with 1 person’s relative via the telephone to gather their experiences of the care and support provided to their family member. In the absence of the registered manager, we spoke with the deputy manager who also provided care to people and a member of care staff. We reviewed a range of records. This included 1 person’s care records, staff training information, 3 staff recruitment records, policies and procedures and records of the checks the registered manager completed to assure themselves people received a safe and good quality service.
Updated
28 February 2023
About the service
Sanctuary Life Care Limited is a domiciliary care service providing personal care to people in their own homes. These can be older people or younger adults living with a learning disability or autistic spectrum disorder, dementia, a physical disability, mental health or sensory impairment. At the time of the inspection three people received personal care.
Not everyone who uses the service may receive 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
People’s individual risks were not always identified, assessed and well-managed. The provider could not demonstrate all planned care had been provided safely because records were not always completed accurately or clearly, to demonstrate safe practice and enable effective monitoring to take place.
Medicines were not always managed safely because some were administered without any medicine administration plans to guide staff on how to do this. Staff recruitment and training records were not sufficient in demonstrating staff were safe, and suitable to work with people.
At the time of our inspection there were enough staff to meet people's needs. Whilst staff knew the people they provided personal care to well, care records were not always in place to help ensure they provided personalised and responsive care.
The provider had failed to operate systems or processes to assess, monitor and improve the quality and safety of the service provided. Audits and checks could not be demonstrated, and the system used to gather feedback about the service from people and their families was ineffective. The lack of robust governance had resulted in the failure to identify the issues that we found.
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 were supported during care calls with food and drinks where needed.
People using the service felt safe. Relatives felt the registered manager and staff were kind and respectful and confirmed care calls were made at times they expected. They knew who to speak with if they had any concerns. Staff felt supported by the provider who was also the registered manager of the service
Following our feedback, the provider told us they had taken action to manage risks and had planned action to improve standards and practice at the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at the last inspection
This service was registered with us on 3 September 2018 and this is the first inspection. The service began providing a personal care service from April 2021.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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 breaches in relation to Safe care and treatment, Fit and proper persons employed, Safeguarding service users from abuse and improper treatment, and Good governance at this inspection.
Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.