Background to this inspection
Updated
8 March 2024
The inspection
We carried out this performance review and assessment under Section 46 of the Health and Social Care Act 2008 (the Act). We checked whether the provider was meeting the legal requirements of the regulations associated with the Act and looked at the quality of the service to provide a rating.
Unlike our standard approach to assessing performance, we did not physically visit the office of the location. This is a new approach we have introduced to reviewing and assessing performance of some care at home providers. Instead of visiting the office location we use technology such as electronic file sharing and video or phone calls to engage with people using the service and staff.
Inspection team
The inspection team consisted of 1 inspector.
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
The inspection was announced. We gave the service 24 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 available to support the inspection.
Inspection activity started on 11 December 2023 and ended on 24 January 2023. We met with the provider remotely on 12 December 2023 and, 23 January 2024.
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. We used all this information to plan our inspection.
The provider did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. Please see the well led section of the full inspection report for further details.
During the inspection
We spoke with 1 person who used the service. We also spoke with 2 care staff and the registered manager who is also the nominated individual. A nominated individual is a person who supervises the management of a regulated activity across an organisation. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We used technology such as electronic file sharing to enable us to review documentation sent to us by the provider.
Updated
8 March 2024
About the service
Body&Soul Assistance, Admin is a is a domiciliary care agency providing personal care to people living in their own houses, flats and specialist housing. At the time of our inspection the service was supporting 1 person with 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.
People’s experience of the service and what we found:
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 assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
The governance of the service was not effective because systems were not in place to identify areas where improvements were needed. The provider did not have a number of governance systems in line with their regulatory requirements. Care plans and risk assessments were basic and there was limited record keeping.
Systems required to ensure the safe recruitment of staff were not in place. However, the person in receipt of services told us they felt safe, staff kept them safe and there were sufficient staff to meet all their needs. Not all staff knew about systems to safeguard people.
We have made a recommendation about staff training on safeguarding.
The person in receipt of care told us that the culture of the service was open and met all their needs. They told us staff helped them manage their medication well and they were responsive to their feedback.
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; 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 last rating for this service was Good (published 06 September 2017).
Why we inspected
We inspected due to the length of time since the last inspection.
We undertook a focused inspection to review the key questions of safe and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection by selecting the ‘All inspection reports and timeline’ link for Body&Soul Assistance, Admin on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to staff recruitment and the good governance at this inspection. We have made a recommendation about staff training on safeguarding.
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.
This was an ‘inspection using remote technology’. This means we did not visit the office location and instead used technology such as electronic file sharing to gather information, and video and phone calls to engage with people using the service as part of this performance review and assessment.