Background to this inspection
Updated
23 June 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 carried out by one inspector.
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
We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.
Inspection activity started on 9 May 2022 and ended on 31 May 2022. We visited the location’s office on 9 May 2022.
What we did before the inspection
We reviewed information we had received about the service and we sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). 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. We used all this information to plan our inspection.
During the inspection
We met with the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We looked at records the provider used for managing the service, including the care records for three people who used the service, three staff files, and other records used by the provider for monitoring the quality of the service. We spoke with one person who used the service, one relative and two members of staff.
Updated
23 June 2022
About the service
Kanssas Home Care - Hayes is a domiciliary care service personal care and support to people of all ages living in their own homes . At the time of our inspection there were four people using the service.
People’s experience of using this service and what we found
We found identified risks had not always been risk assessed and a risk mitigation plan developed, for example around people’s mobility and COVID-19 risk assessments.
We have made a recommendation about the management of COVID-19 risk assessments.
People were generally 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; the policies and systems in the service supported this practice. However, we saw one person’s records were signed by a relative. The registered manager told us the relative had the authority to do so but did not have any evidence to demonstrate the person’s authority.
We have made a recommendation about considering current guidance around the Mental Capacity Act 2005 and taking action to update their practice and records accordingly.
The provider did not always maintain contemporaneous records which meant people were at risk of not receiving the care and support they required.
The provider had some quality monitoring process in place, but these had not always been effective as they had not enabled the provider to identify and address the issues we found during the inspection.
People told us they felt safe with the care provided. The provider followed safe recruitment practices to help ensure suitable people were employed. Staff received appropriate training to meet people’s care needs.
Care plans provided background information including people’s cultural and religious needs, and how they would like their car to be provided. People were supported by the same staff who were kind and caring.
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 1 April 2020 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 safe care, person centred care and good governance.
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 continue to monitor information we receive about the service, which will help inform when we next inspect.