Background to this inspection
Updated
19 July 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 24 hours’ notice of the inspection. This was because we needed to be sure the provider or registered manager would be in the office to support the inspection.
Inspection activity started on 16 May 2023 and ended on 26 May 2023. We visited the location’s office on 16 May 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. 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 4 people who used the service and 6 relatives about their experience of the care provided. We spoke with 12 members of staff including the registered manager, deputy manager, compliance coordinator and care staff. We also received feedback from 2 health professionals who have contact with the service.
We reviewed a range of records. This included 11 people’s care records, 3 staff files in relation to recruitment, feedback and satisfaction surveys from people and relatives and a variety of records relating to the management of the service.
Updated
19 July 2023
About the service
Chenai Holistic Care Home Care Agency Ltd is a domiciliary care agency providing personal care to people living in their own homes. 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. At the time of our inspection there were 111 people receiving personal care support.
People’s experience of using this service and what we found
The provider’s processes for reviewing the quality and safety of the service were not always effective and systems in place to monitor people’s care visits were not robust. We could not be assured the deployment of staff was appropriate to people’s needs. We have made a recommendation about the provider’s processes for monitoring the deployment of staff. The provider had systems in place to recruit staff safely; however, not all checks were fully documented. Risks to people’s safety were assessed; however, some information lacked personalisation and detail.
People and relatives spoke positively about the staff and management team. Staff understood people’s needs and how they liked to be supported. 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. People and relatives told us staff were kind, caring and respectful in their support.
Staff knew how to report any concerns or signs of abuse. People and relatives told us they had no concerns about safety. Staff had access to appropriate personal protective equipment [PPE] and the provider had ensured there was updated guidance in place to manage any infection control risks. Staff supported people to take their medicine safely and people’s care plans contained information about their medicines support needs.
People and relatives felt involved in the service and the provider sought monthly feedback to ensure people were satisfied with their care. Staff told us they felt supported and were able to contact the management team if they had any queries or concerns. The provider worked in partnership with other health and social care professionals in order to meet people’s support needs and respond to any changes in their health.
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 20 December 2021) and there were breaches of regulation.
At this inspection not enough improvement had been made and the provider was still in breach of regulation. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections
Why we inspected
We carried out an announced inspection of this service on 21 October 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and governance.
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, Caring and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement.
Enforcement and Recommendations
We have identified a breach in relation to the provider’s oversight and governance processes. 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.