Background to this inspection
Updated
23 December 2023
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 1 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 is a domiciliary care agency. It provides personal care to people living in their own houses and flats.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
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.
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. 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 spoke with 5 people who use the service and 6 relatives about their experience of the care provided. We spoke with 8 staff including the branch manager, support workers, senior support workers and the registered manager. The registered manager is also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records including records relating to medicines, staff recruitment, support plans, risk assessments, accidents and incidents and safeguarding logs. We also looked at a variety of records relating to the management of the service including audits and policies and procedures.
Updated
23 December 2023
About the service
Complete care Services Rossendale is a domiciliary care service providing personal care to people living in their own homes. The service provides support to younger adults and older people with a physical disability, sensory impairment, learning disabilities or autistic spectrum disorder. At the time of our inspection there were 68 people using this service, including 58 people who were receiving personal care.
Not everyone who used the service 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.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support
Risks to people’s health and safety were managed well. People were 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. However, the policies and systems in the service did not always support this practice as consent to care forms were not always in place. We made a recommendation about this. There were enough skilled and experienced staff to safely care for people and recruitment processes were safe. We were assured IPC practices were safe. Staff treated people well and people were supported to make their own decisions about the care they received.
Right Care
Medicines were mostly managed safely. However, we found protocols were not in place to guide staff on ‘as required’ medicines. We made a recommendation about this. People’s needs were assessed prior to them starting to use the service and these assessments helped to develop person centred risk assessments and plans. People had been involved in the care planning process and staff had time to read people’s care plans. People’s privacy, dignity and independence was respected and promoted.
Right Culture
Governance systems could be further strengthened to ensure the provider was working in line with their policies and procedures. We made a recommendation about this. The provider had a robust lessons learnt procedure in place and we saw evidence of concerns being shared amongst the staff team through staff meetings and learning. There was a complaints procedure in place and people and their relatives told us they had no need to complain about the service. Staff had their competency checked regularly though spot checks and supervision. Staff were aware of their safeguarding responsibilities and felt comfortable raising concerns. People and staff spoke highly of the management team.
For more details, please see the full report for Complete Care Services Rossendale which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 18 January 2022 and this is the first inspection.
The last rating for the service under the previous provider was good, published on 7 November 2018.
Why we inspected
The inspection was prompted due to Complete Care Services Rossendale being a newly registered service.
Recommendations
We made recommendations in relation to the management of medicines, consent and overall governance at this service.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.