28 August 2019
During a routine inspection
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
Not all risks to people’s health and safety had been identified and assessed. Risk assessments did not always contain guidelines for staff about how to reduce risk and support people to remain safe. There was no evidence that people’s needs were assessed before they started using the service.
People’s records did not always contain the correct or necessary information and there was a risk staff would not know how to meet people’s individual needs. Where there were care guidelines, these were sometimes basic and lacked detail.
People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.
Where a person lacked the mental capacity to make a decision, the provider did not always make sure others making decisions for them had the legal authority to do so.
The provider carried out a range of checks and audits to monitor the quality of the service and make improvements where needed. However, these had not always been effective and had failed to identify some of the areas for improvement we found.
People who used the service and their relatives were happy with the service they received. People said the staff were kind, caring and respectful and they had developed good relationships with them.
The provider worked with other professionals to help make sure people had access to health care services. People received their medicines safely and as prescribed. People’s nutritional needs were assessed and met.
Staff were happy and felt well supported. They enjoyed their work and spoke positively about the people they cared for. They received the training, support and information they needed to provide effective care. The provider had robust procedures for recruiting and inducting staff to help ensure only suitable staff were employed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 9/8/2018 and this is the first inspection.
Why we inspected
This was a planned inspection based on the date the service registered.
We have found evidence that the provider needs to make improvement.
Enforcement
We have identified breaches in relation to safe care and treatment, person-centred care, need for consent and good governance.
Please see the action we have told the provider to take at the end of this report.
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.
We will request an action plan for 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.