23 June 2022
During a routine inspection
Freivan Support Services is a domiciliary care agency registered to provide personal care. At the time of the inspection, four people were receiving support with personal care.
People’s experience of using this service and what we found
Risks to people were not always recorded or mitigated against. Recruitment processes were not always robust. The provider was unaware of up to date guidance on infection prevention and control and did not record staff testing satisfactorily.
Care plans were not always person-centred; People needs were not always recorded correctly and we found an instance where information had been copied from one person’s care plan to another. Relatives told us people’s communication needs were met but the provider was not recording these in sufficient detail. People’s end of life wishes were not recorded. We have made a recommendation about this.
The provider did not have up to date oversight of staff training and had not made observations of staff at work.
Quality assurance systems and processes at the service were ineffective. The provider had not completed any spot checks at the time of the inspection nor audits of care plans or staff files.
At the time of inspection no one was being supported to have their medicines administered.
Staff were trained to safeguard adults from abuse and there had been no incidents or accidents at the service.
Assessments of people’s needs had been completed with people in line with the law. The service recorded people’s care in communication logs. People’s nutrition and hydration needs were met. People’s care was carried out in their best interests and staff understood the law in this regard.
Staff were respectful of people’s equality and diversity. People and relatives told us staff treated people well. People and relatives were able to make their views known to the service. People’s privacy and dignity were respected, and their independence promoted.
People and relatives told us they would feel comfortable to complain if required.
Staff were clear about their roles. Management were able to tell us how they would respond if things went wrong. The service sought to work with other agencies to the benefit of others.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 13 April 2021 and this is the first inspection.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
You can see what action we have asked the provider to take at the end of this full report.
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 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 breaches in relation to recording risk and governance at this inspection.
We have made two recommendations to the provider. We have recommended they follow best practice guidance around observing staff and recording people’s end of life wishes.
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.