Background to this inspection
Updated
14 December 2022
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 was conducted 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 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 a short period notice of the inspection for this inspection carried out using our remote technologies.
Inspection activity started on and ended on 15 November 2022.
What we did before the inspection
We looked at all the information we held about the provider. This included information we gathered when the service was registered and when they first started providing personal care and support to people. 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.
During the inspection
This performance review and assessment was carried out without a visit to the location’s office. We used technology such as telephone calls to enable us to engage with people using the service and staff, and electronic file sharing to enable us to review documentation. We had a call meeting with the registered manager.
We spoke with two people who used the service and the relatives of five people who used the service. We spoke with two care assistants. We looked at the care records for four people who used the service, staff records and other records used by the provider for managing the service.
Updated
14 December 2022
About the service
Charlotte's Compassionate Care Services Ltd is a domiciliary care agency providing personal care and support to people living in their own homes. This is the only branch of this private limited company.
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 10 older people were using the service.
People’s experience of using this service and what we found
The provider's systems for identifying, recording and planning for risks were not always robust enough and records were not always clear. In particular, the provider had not always assessed and planned for risks regarding medicines.
The systems to ensure staff were suitable and had the skills and knowledge needed to care for people were not always followed because the provider did not always make thorough checks at recruitment and had not always recorded when they checked staff competencies or skills.
The systems for monitoring and improving the quality of the service were not always effectively implemented because they had not always identified where improvements were needed.
People using the service were happy with their care and support and generally felt communication with the agency was good. People and their relatives said the staff were kind, caring and reliable.
The staff felt well supported and liked working at the agency.
People were involved in planning their own care and making decisions about this.
There were systems for monitoring and learning from accidents, incidents and complaints. Although there had not been any at the time of our inspection. There were a range of policies and procedures which staff were aware of. People told us the provider had apologised when things had gone wrong and worked with them to improve the service.
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
This was the first inspection of the service since it was registered on 27 October 2021.
Why we inspected
The inspection took place based on the date the service was registered with us.
Enforcement and Recommendations
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 breaches in relation to safe care and treatment, fit and proper persons employed and good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
We have made a recommendation about ensuring staff training and competencies are assessed and recorded.
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.