20 April 2022
During an inspection looking at part of the service
180 Surrey Street is a domiciliary care service. It provides care for people living in their own houses and flats. 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. At the time of our inspection, 16 people were receiving personal care.
People’s experience of using this service and what we found
Risk assessments in relation to people’s care needs were inconsistently detailed and had not been reviewed at the frequency the provider had identified as required. Medicine administration records had not been audited regularly as per the provider’s audit process and records reviewed showed there were missing staff signatures.
Care calls were not effectively monitored, and shortfalls were identified in how care calls had been provided.
The complaints log had not been kept up to date. However, people told us they knew how to make a complaint and complaints, or concerns had been acted upon by the management team.
We received a mixed response about people’s experience of being advised if care staff were running late. Some people told us they were informed and others not.
Staff had received training on infection prevention and control and wore personal protective equipment. Some people raised concerns that staff did not always wear masks or wore them correctly. This was shared with the registered manager who agreed to follow up with staff.
There were sufficient staff available, however, the registered manager and office manager covered staff shortfalls, and this impacted on the monitoring of care calls. Staff were overall recruited safely and received an induction, training and ongoing support.
Overall, people were positive about the staff competency and approach to care. Positive feedback was received about the management team and support.
Staff spoke positively about working for the provider and felt well supported, valued, and listened to. Staff received ongoing training and opportunities to discuss their work.
Staff were aware of their responsibilities to protect people from abuse and avoidable harm. People felt they received safe care and support. The provider had systems and processes to manage incidents and incident records were reviewed for any learning opportunities.
People were involved in decisions about their care. Review meetings had been conducted and spot checks completed to check staff’s competency and to gain feedback from people who used the service.
Staff worked with external professionals to support people’s needs and outcomes.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good (published 3 April 2019).
Why we inspected
We received concerns in relation to the quality and safety of care provided.
As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements.
Please see the Safe and Well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 180 Surrey Street on our website at www.cqc.org.uk.
Enforcement
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 governance of the service 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.