LCS Portsmouth

Updated 28 October 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

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.

Notice of inspection

This inspection was announced. 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 13 September 2022 and ended on 22 September 2022. We visited the location’s office on 13 September 2022.

What we did before the inspection

We reviewed information we had received about the service since they were registered, including

notifications. Notifications are information about specific important events the service is legally required to send to us. 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 information gathered as part of monitoring activity that took place on 18 July 2022 to help plan the inspection and inform our judgements.

We used all this information to plan our inspection.

During the inspection

We spoke with eight people who use the service or their family members. We sought feedback from the local authority and professionals who work with the service and received responses from three of them. We spoke with four care staff members, the registered manager and three office staff members. We also spoke with the provider's nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records, including five people's care records. We looked at five staff files in relation to recruitment and records relating to staff training. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 28 October 2022

About the service

LCS Portsmouth is a domiciliary care agency which provides support and personal care to people living in their own home. 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 20 people were receiving a regulated activity.

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

Although people that received care from LCS Portsmouth were generally happy with the care they

received, we found shortfalls in the safety and management of the service which placed people at risk of harm.

The provider's quality assurance processes were not effective and had failed to identify concerns we found and improve the quality and safety of the services provided.

Not all risks for people had been fully assessed and plans put in place to mitigate those risks as far as possible. Where risk assessments were in place these had not been regularly reviewed to ensure risk mitigation measures remained appropriate or additional risk assessments were implemented when required.

Although staff supported people in the least restrictive way possible and in their best interests to have maximum choice and control of their lives the systems in the service did not ensure people’s legal rights under mental capacity legislation were fully met.

Recruitment procedures were not always effectively followed to ensure only suitable staff were employed. Staff told us they felt supported however, formal processes to ensure staff were supervised according to the provider’s policy were not being followed.

Staff had not been assessed as competent to administer medicines safely. Procedures were not in place or followed to ensure medicines were always been managed safely.

People told us they felt safe when receiving a care service and staff and the registered manager were aware of their safeguarding responsibilities.

Staff told us they always had enough Personal Protective Equipment (PPE) and had not experienced a shortage during the COVID-19 pandemic. They described how and when they would use PPE which reflected current guidance.

People and their family members were all positive about the caring nature of the staff. People told us they were always treated with dignity and respect. People felt able to express their views and request additional tasks be completed if required.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This service was registered with us on 8 March 2021 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 risk assessment, staff recruitment, medicines management, MCA and quality monitoring of the service at this inspection.

We have recommended that the provider review their procedures to ensure care plans are regularly reviewed to ensure they accurately reflect people's needs.

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

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 continue to monitor information we receive about the service, which will help inform when we next inspect.