Castlewood Road

Updated 30 November 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 Health and Social Care Act 2008.

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.

This service is also registered to provide care and support to people living in a ‘supported living’ setting, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

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

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.

What we did before the inspection

We reviewed information we had received about the service and formal notifications that the service had sent to CQC. Notifications are information that registered persons are required to tell us about by law that may affect people's health and wellbeing. The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. Please see the well led section of the full inspection report for further details. We used all this information to plan our inspection.

During the inspection

We spoke with the relative of a person using the service. We spoke with three members of staff including one member of support staff who was also the Nominated Individual, the director of finance and administration and the Registered Manager. The Nominated Individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records, including a person’s care records, three staff files in relation to recruitment and staff support. We looked at a variety of records relating to the management of the service, including policies and procedures and audits. We sought feedback from the local authority.

Updated 30 November 2022

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

At the time of the inspection, the location did not provide care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

About the service

Castlewood Road is a domiciliary care service that provides personal care to adults with a range of support needs living in their own home or within a supported living setting. At the time of the inspection the service was providing personal care to one person living in their own home in the local community.

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

A relative spoke positively of the service and told us their relative was safely supported. However, despite this positive feedback we found issues with the management of a person’s risks, staff recruitment and management oversight.

The service had systems in place to monitor the quality and safety of the service, however they did not identify the issues we found during the inspection.

We found examples where a person’s risks had not been sufficiently assessed and documented in their care records.

We found safe recruitment procedures were not being followed.

We made a recommendation around the personalisation of people's care records.

Staff followed infection prevention and control measures

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.

A person was supported to access and maintain a balanced and healthy diet where required.

A relative told us a person was supported by kind and caring staff that respected their privacy and supported their independence.

Staff knew the person using the service well, however aspects of a person’s care plan were not detailed or up to date. A person and their relative were involved in the planning and reviewing of their care.

The management team sought the views of people using the service. A person’s relative told us they were satisfied with the service received.

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 17 December 2019 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well led sections of this full report.

Enforcement and Recommendations

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, staff recruitment and good governance 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 continue to monitor information we receive about the service, which will help inform when we next inspect.