180 Surrey Street

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.

People’s experience of using this service:

• People were protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe.

• People's risks were assessed and strategies put in place to minimise the identified risks.

• People's needs and preferences were assessed and care packages met people's desired expectations.

• Recruitment procedures ensured only suitable staff worked at the service.

• People and their relatives provided positive feedback about the care, staff and management.

• People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were treated with kindness, respect and understanding.

• People's care was person-centred. Staff provided care designed to ensure people's independence was encouraged and maintained.

• Staff received training that enabled them to deliver the support that people needed. Staff received support from the registered manager.

• People and their relatives were involved in the care planning and review of their care.

• The service had a stable management structure. The provider had implemented systems to ensure they continuously measured the safety of people's care and quality of the service.

Rating at last inspection: This was the first comprehensive inspection carried out at 180 Surrey Street since they registered with CQC in December 2017

Why we inspected: This was a scheduled inspection to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our reinspection programme. If any concerning information is received we may inspect sooner.

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