15, 22 September 2014
During a routine inspection
Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, and the staff supporting them and looking at records.
The agency provided a service to 90 people and employed approximately 60 care staff. The service did not have a registered manager. The care delivery director for the region was in the office during one day of our visit and the current manager of the service was in the office for both of the days. This manager advised us they would be submitting an application with us to become the registered manager. During this inspection we contacted 12 staff members and 16 people who used the service.
Is the service safe?
We found that there systems in place to ensure the manager and staff learned from events such as accidents, incidents and investigations. This reduced the risks to people and helped the service to continually improve. We found that the provider did not have an effective recruitment procedure to ensure the safety of people. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to recruiting new staff.
Is the service effective?
We found people had received an assessment before their care began. People had care plans but the detail of information recorded in these varied and formal reviews had not necessarily taken place if the care package had changed. Staff told us they had received a good induction and on-going training to equip them to meet people's needs.
Is the service caring?
People told us they were supported by kind and attentive staff. One person told us, 'They know me as an individual, they know everything about me'. People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these had been addressed.
Is the service responsive?
People told us they knew how to make a complaint if they were unhappy. One person said that they had made a complaint and were satisfied with the outcomes. We looked at how these complaints had been dealt with, and found that the responses had been open, thorough, and timely. People could therefore be assured that complaints were investigated and appropriate action taken. People spoke highly of the office staff and told us they were helpful and polite.
Is the service well-led?
The service had been without a registered manager for some time and we found there were areas where there had been a lack of overall monitoring. These areas included regular reviews of care plans, records of supervision sessions with staff and staff recruitment records. The service did have a quality assurance system; records seen by us showed this identified some shortfalls were addressed promptly. Staff told us they were clear about their roles and responsibilities.