Background to this inspection
Updated
30 June 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 conducted by one inspector.
Service and service type
This service is a domiciliary care agency. It provides personal care to people living in their own homes. This is help with tasks related to personal hygiene and eating.
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 no registered manager in post. The provider was recruiting a person for this position.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because we needed to be sure that the provider or registered manager would be in the office to support the inspection.
Inspection activity started on 26 May 2022 and finished on 07 June 2022. We visited the office location on 26 May 2022.
What we did before the inspection
We reviewed information we had received about the service since it had registered with us.
The provider completed a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
We used this information to plan our inspection.
During the inspection
We spoke with one person and relatives of three people who used the service. We spoke with the nominated individual, a director and the care co-ordinator and three care workers. A nominated individual supervises how regulated activity is managed.
We reviewed a range of records. This included two people's care records, two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including complaints, incident forms, policies and procedures were reviewed.
We requested additional evidence to be sent to us after our inspection. This including the service user handbooks and records relating to governance including policies and procedures.
Updated
30 June 2022
About the service
Leys Consultants is a domiciliary care agency providing personal care to people in their own homes.
At the time of the inspection, there were eight people using the service. Not everyone who used the service received personal care. At the time of our inspection they were providing personal care to four older people , some with a diagnosis of early dementia. 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
Although we received positive feedback from people, relatives and staff about how the service was managed, we found there were a lack of quality assurance checks to monitor the quality of the service. Some policies were out of date, there were no formal methods of auditing records and to identify some of the issues we found at this inspection.
Staff were given training that was relevant to the needs of people using the service. However, we found that staff induction checklists, supervisions and competency checks were not being completed or recorded.
We have made a recommendation to the provider in relation to formal engagement with people, staff and other relevant stakeholders.
People and their relatives were satisfied with the service and care they received. They told us they had no concerns around safety. There were enough care workers employed who continued to meet people’s needs. Infection control practices were safe. Risks to people were assessed and managed, this helped to the provider to deliver care in a safe way.
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.
The provider sought appropriate consent from people before starting to support them. People were supported by the provider to meet the health and dietary needs. .
The service was caring, this was reflected in the feedback we received from people and their relatives. Care workers demonstrated a good understanding of people’s support needs and cared for them in a dignified and respectful manner. People were involved in planning and directing their own care.
Care plans were person centred, containing the views of people using the service. They were written in a manner that promoted independence and care workers supported people in line with their individual preferences. People and their relatives were given details about how and who to complain to if they were not satisfied with their care.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This was the first inspection of the service since it registered with the CQC on 16 October 2020.
Why we inspected
This was a planned inspection based on when the service registered with us.
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 staffing and good governance at this inspection. Please see the action we have told the provider to take at the end of this full report.
Follow up
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk