3 September 2021
During a routine inspection
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.
People’s experience of using this service and what we found
At the last inspection we found the provider was in breach of regulation 12 and 17 as governance systems were not robust and medicines were not managed safely. We also made a recommendation for the provider to improve their staffing. At this inspection we found the service had not made enough improvement and remained in breach of these regulations.
The provider failed to assess, monitor and improve the quality of the service and maintain accurate and robust care records. We found shortfalls in recordings; for example, medication administration records (MARs), care plans and risk assessments were not always signed, updated or completed.
Medicines were not always managed safely. People we spoke with were not confident their medicines were administered at the correct times due to visits being late. Medication administration records (MARs) were not always accurately written or signed for by staff following administrations.
We found evidence staffing levels were not adequate as rota’s showed staff did not always stay the allocated times. People we spoke with and their relatives said staffing levels were not sufficient as visits were often late or missed due to staff shortages.
Some care plans lacked up to date and accurate information to guide staff. Risks to people and how they were managed were not always fully reflected in risk assessment documentation. Staff knew people’s needs and how to care for them however, some people we spoke with said staff required further training to meet their needs.
People told us they felt safe with staff visiting their homes. There were systems in place to recognise and respond to any allegations of abuse.
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. Basic information was recorded for people’s capacity status however, decision specific capacity assessments and best interest decisions had not been recorded.
People told us staff were kind, caring and supportive. People's privacy was valued by staff who maintained people’s dignity. Staff ensured they always offered choice and encouraged people to remain independent when their health allowed.
Complaints we looked at were managed with actions taken to address the concerns and most people felt their concerns would be responded to.
Staff were aware of infection control practices in relation to the latest COVID-19 government guidance for the use of personal protective equipment (PPE) to keep people and staff safe.
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 the service under the previous provider was rated good (published 4 July 2019). CQC carried out a responsive inspection of Be Caring Leeds looking at the safe and well led key questions and found two breaches of regulation 12 and 17 (published 21 April 2021). The overall rating published on 21 April 2021 was requires improvement.
Why we inspected
The inspection was prompted in part due to concerns received about safe care and treatment. We had been contacted by the local safeguarding team about ongoing concerns within the service. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvement. Please see the safe, effective, caring, responsive 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 focused inspection, by selecting the ‘all reports’ link for Be Caring Leeds 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified three breaches in relation to safe care and treatment, staffing and governance.
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 continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.