Archived: BDW Care Ltd

Updated 12 August 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

This inspection was carried out by one inspector. One Expert by Experience supported the inspection by making telephone calls to people and their relatives. 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.

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 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 in the office to support the inspection.

Inspection activity started on 13 July 2021 and ended on 30 July 2021. We visited the office location on 13 July 2021.

What we did before 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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with seven relatives about their experience of the care provided. We spoke with the registered manager, director, care coordinator and three care workers.

We reviewed a range of records. This included three people’s care records and medication records. We looked at three 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.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We received written feedback from four professionals who support the service.

Updated 12 August 2021

About the service

The Rainbow Care Group is a domiciliary care agency providing personal to people living with dementia in their own homes. The service was supporting 10 people at the time of inspection.

Not everyone who used the service received personal care. The Care Quality Commission (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

There was no established auditing system to improve the quality and safety of the service. This meant the provider had failed to identify the improvements required at the service.

When checks were carried out such as medicine checks, spot checks and surveys they had not been used to improve the service. Records were not always accurate, up to date or fully complete.

Records were not always completed for staff induction, and systems were not effective to record and monitor training.

Recruitment records were not robust. We have made a recommendation about recruitment.

Tools were used to assess the risk levels, but control measures were not always put in place when required. Staff had knowledge of how to mitigate risks to people. We have made a recommendation about the management of risk.

People were happy with the support they received with their medicines; however, best practice was not always followed.

People were supported by a consistent staff team who they had developed positive relationships with. Staff treated people with respect and maintained their privacy and dignity.

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.

The service worked in collaboration with health and social care professionals and we received positive feedback regarding the service and partnership working. People were supported with their nutritional needs when this was part of their care package.

People received person centred care. The provider was passionate about ensuring people received stimulation and activities.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection This service was registered with us on 06 March 2020 and this is the first inspection.

Why we inspected

This was a planned inspection.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to governance. 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.