Voyage (DCA) Gloucester

Updated 21 July 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

Two Inspectors, a member of the CQC medicines team and an Expert by Experience carried out the inspection. 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

Fox Elms Care Limited provides personal care to people with a learning disability, mental health diagnosis or acquired brain injury living in their own homes or in supported living accommodation. 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.

The service had a manager registered with the Care Quality Commission. 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. The registered manager was due to be leaving the service and deregistering. The provider had identified a new manager who intended to register with the Care Quality Commission. The provider had scheduled for a handover period between the new and existing manager to ensure a handover of information was prioritised.

Notice of inspection

This inspection was announced. We gave the service 72 hours’ notice of the inspection. This was to ensure that people and staff would be available during the inspection and to ensure people's relatives could agree to be contacted by the inspector by telephone as part of our inspection. Inspection activity started on 13 June 2022 and ended on 16 June 2022. We visited the location’s office on 13 and 15 June 2022.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR) in July 2021. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We communicated with seven people who used the service and 11 relatives about their experience of the care provided. People who used the service, who were unable to talk with us, used different ways of communicating including using Makaton, pictures, objects and their body language.

We spoke with 23 members of staff including care staff, Field Support Workers, Service Optimisation Managers, the deputy manager, Registered Manager and the Acting Operations Director.

We reviewed a range of records. This included four people’s care records and a sample of medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policies and procedures, training information and quality assurance records. We gathered feedback from nine professionals who regularly visit the service.

Updated 21 July 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.

About the service

Fox Elms Care Ltd is a domiciliary care service providing personal care to those with a learning disability or complex needs in their own homes or a supported living setting.

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

The service was partially able to demonstrate how they were meeting the underpinning principles of ‘Right support, right care, right culture’.

Right Support

People had a choice about their living environment and were able to personalise their rooms. People could access specialist health and social care support in the community. The provider was working to improve and develop the relationships with healthcare professionals and the local authority.

Right Care

The service did not always ensure that risks faced by people in relation to medicines, epilepsy and infection control had been consistently identified, assessed and planned for. The provider was working to ensure the records relating to the management of people’s care were up-to-date and reflective of their needs.

Right Culture

The provider had not had consistent oversight of the service since our last inspection. There had been a delay in implementing an effective quality assurance system which meant that records were inconsistent and the culture at the service was not always positive. Prior to our inspection a new senior management team had implemented a service improvement plan. They had made considerable progress, although more time was needed to fully implement and embed the necessary improvements.

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

Why we inspected

This inspection was prompted in part by the provider's notification to CQC of a significant event. The information shared with CQC about the incident indicated potential concerns about safe care and treatment. We also undertook this inspection to assess that the service is applying the principles of Right support right care right culture.

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 a breach in relation to Regulation 17 (Good governance).

We have made a recommendation about the management of some medicines.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.