Background to this inspection
Updated
29 January 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 Care Act 2014.
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, flats and specialist housing.
The service had a manager registered with the Care Quality Commission. 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.
Notice of inspection
Inspection activity started on 24 November and ended on 14 December 2021. We visited the office location on 08 December to meet the registered manager and to review records related to the service.
What we did before inspection
We reviewed information we had received about the service. The provider was not asked to complete the required Provider Information Return. This is information providers are required to send us with key information about the service, what it does well and improvements they plan to make. We took this into account in making our judgements in this report.
During the inspection
We reviewed a range of records. This included one person’s care records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We spoke with one relative and a member of staff.
Updated
29 January 2022
About the service
MAM T Healthcare Limited is a domiciliary care agency providing personal care to people in their own homes. The service was supporting one person. At the time of the inspection, two members of staff who worked at the person’s accommodation were also employed by MAM T healthcare to provide personal care to this person.
People’s experience of using this service and what we found
Risk assessments were not always carried out to ensure potential risks to the person were identified and managed safely. The registered manager was not checking and ensuring staff were being tested for COVID-19 in line with government guidance.
The registered manager was not monitoring call times due to the size of the service. This meant we were not assured that care was always carried out at the agreed times. We have made a recommendation to the registered manager to establish systems to monitor care calls to ensure people receive care at their agreed times.
The registered manager was not aware of their responsibilities under the accessible information standard. We made a recommendation to the provider to attend training and update their working practices.
Due to the size of the service the registered manager did not have systems in place to monitor the quality of the service. This meant the registered manager did not have adequate quality assurance systems in place to improve service delivery and to review the care that was being provided to this person.
The registered manager did not have up to date care plans in place which meant there was not detailed information about how people would like their care to be received.
The registered manager had not provided training to the staff team as they had sought evidence of training certificates from previous employers which demonstrated that they had the appropriate skills to care for people.
Staff understood the provider’s safeguarding policies and were familiar with the reporting procedures.
The person’s relative was happy with how the care and support was being delivered and felt that the care staff were kind and helpful.
The person was supported to have maximum choice and control of their life and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The service was registered on 05 November 2021, but it was previously registered at a different location. This was the service’s first inspection.
Why we inspected
We carried out this inspection following a routine review of information we held about this service. Our intelligence indicated there may be a higher level of risk at this service due to the length of time it had been registered and not been inspected.
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. 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 identified breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safe care and treatment (regulation12) and good governance (regulation 17). Please see the 'action we have told the provider to take' section towards the end of the report.
Follow up
We will continue to monitor intelligence we receive about the service which will dictate when we return to inspect. If any concerning information is received, we may inspect sooner.