81 Wood Lane

Updated 21 September 2022

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 one 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

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 the service is small 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 5 July 2022 and ended on 14 July 2022. We visited the location’s office on 5 July 2022.

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. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with four members of staff including the registered manager, director and two staff members. We spoke with two people who used the service. We reviewed two people’s care plans and medication records. We reviewed two staff recruitment files and training information. A variety of records relating to the management of the service, including how the provider monitored the quality of the service were reviewed. We continued to seek clarification from the provider to validate the evidence found.

Updated 21 September 2022

About the service

81 Wood Lane is a domiciliary service providing personal care to three people at the time of the inspection.

People’s experience of using this service and what we found

Whilst we noted improvement in the systems around medicine management, further improvement was needed around the records of medicines given on an ‘as required’ basis. Additionally, further improvement was needed to ensure all risks to the person were clearly documented in people’s care plans and risk assessments.

There remained a lack of a formalised structure to enable new staff to be inducted into the service, supervised regularly and their competence reviewed.

Some improvement had been made to the systems that monitored the safety in the service. However, further improvement was needed to ensure these systems became effective at identifying concerns. This would enable the provider to have full oversight of the quality of people’s care

People were supported by staff who understood how to recognise and escalate safeguarding concerns should they have any. Improvements had been made to the recruitment systems in place.

People told us that staff had the necessary skills to support them safely. Staff had received training in most of people’s individual support needs.

People had received support with their healthcare needs and the provider worked in conjunction with a number of healthcare professionals to ensure people received continuity of care.

We received positive feedback from the people who received care. Improvements had been made in seeking feedback from people who received support from the service.

Staff knew the people they were supporting well and felt supported by the registered manager.

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 and update

The last rating for this service was Inadequate (published 9 December 2021) and there were breaches of regulation relating to safe recruitment practices, supporting people safely, ensuring staff were inducted and supervised appropriately and in the monitoring of the service. We placed conditions on the providers registration that required them to send CQC monthly reports on key areas.

At this inspection enough improvement had been made to ensure staff were recruited safely and that people received safe care and the provider was no longer in breach of these regulations (Regulation 12 Safe Care and Treatment and Regulation 19 Fit and Proper Persons Employed). However, insufficient improvement had been made in ensuring staff were inducted and supervised appropriately and in the monitoring of the service and the provider remains in breach of these regulations (Regulation 18 Staffing and Regulation 17 Good Governance.)

This service has been in Special Measures since 9 November 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well Led sections of the report.

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 changed from Inadequate to Requires Improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 81 Wood Lane on our website at www.cqc.org.uk.

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 monitor the service and will take further action if needed.

We have identified a continued breach relating to the governance and oversight at the service (Regulation 17 Good Governance) and ensuring staff are appropriately inducted and supervised (Regulation 18 Staffing). We will continue to monitor the improvement within the service through existing conditions we have placed on the providers registration. This includes sending us monthly reports of action the provider has taken to make improvements within the service.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.