Background to this inspection
Updated
7 September 2021
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 team consisted of an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is owned or rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.
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
We gave the service 48 hours’ notice of the inspection. This was because it is a service across three schemes and we needed to be sure that the provider or registered manager would be in the office and available to support the inspection.
Inspection activity started on 11 June 2021 and ended on 26 July 2021. We visited the office location on 22 July 2021.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with three people who used the service and three relatives about their experience of the care provided. We spoke with twelve members of staff including the registered manager, project manager, team leaders and care workers.
We reviewed a range of records. This included six people’s care records and medication records. We looked at four 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.
Updated
7 September 2021
About the service
Creative Support – Bedfordshire Service provides personal care and support to people living in ‘extra care housing’. People using the service lived in flats in three buildings across Bedfordshire. At the time of this inspection 33 people were using the service.
Not everyone living at the schemes 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
People had positive experiences of using the service and told us they felt safe. People were supported by teams of regular, consistent staff. There were enough staff to support people and meet their needs.
The provider had robust recruitment procedures in place and completed relevant checks before staff worked at the service.
Staff had been trained and understood the principles of safeguarding people from harm. Risk to people's health, safety and wellbeing had been identified and assessed. Staff knew the actions they needed to take to support people to stay safe.
Medicines were managed safely, and staff followed good infection control practices.
People were involved in planning their care. Care plans in place reflected people’s needs and preferences. Staff knew people well and understood how their identified needs should be met.
The provider had systems in place to obtain people’s feedback about the service and to seek their views.
There were quality assurance systems in place to monitor all aspects of the service. There were processes in place to manage accidents, incidents and complaints and to ensure these were investigated and learned from. Audits were completed to monitor all aspects of the service. Action plans were in place to ensure any issues found were addressed and improvements made when identified as required.
People, relatives and staff spoke highly of the registered manager. All staff felt supported by the registered manager to complete their roles and were provided with the guidance, training and support they needed.
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
The last rating for this service was requires improvement (published 25 June 2019).
The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an announced comprehensive inspection of this service between 03 June 2019 and 07 June 2019. Breaches of legal requirements were found and recommendations made. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe recruitment, governance and the absence of a registered manager.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements and recommendations.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Creative Support – Bedfordshire Service on our website at www.cqc.org.uk.
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.