Background to this inspection
Updated
8 February 2020
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
The inspection was completed by one inspector.
Service and service type
This service is a domiciliary care agency. It provides personal care to retired nuns living at Rosary Priory, Bushey Heath.
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. The registered manager had recently transferred to a different role within the provider organisation and a new manager had been appointed. The registered manager continued to work at the location to support the new manager and assist in the transition of the management of the service to them. The new manager was not present during our inspection visit due to ill health.
Notice of inspection
We gave the service 48 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.
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. 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 three Sisters who used the service about their experience of the care provided. We spoke with four members of staff including the registered manager, senior care worker and care workers. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included two Sister’s care records and medication records. We looked at two 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 also reviewed.
After the inspection
We continued to seek clarification from the registered manager to validate evidence found. We looked at training data, meeting minutes, staff guidance documents and quality assurance records.
Updated
8 February 2020
About the service
Sanctuary Home Care Ltd – Bushey Heath is a domiciliary care agency providing personal care. The agency is located in Rosary Priory, Bushey Heath and provides a service to the Dominican Sisters of Saint Catherine of Siena Newcastle, Natal who live at the priory. At the time of our inspection, the service was providing personal care to nine people (referred to as Sisters throughout the report).
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.
The agency does not provide any services to the wider community.
People’s experience of using this service and what we found
The Sisters consistently told us they were safe and trusted their care staff. Staff understood their responsibilities with regards to safeguarding and they had received effective training. There were systems in place to safeguard the Sisters from the risk of possible harm. The service had robust recruitment procedures in place.
The Sisters needs had been assessed and they had been involved in planning and deciding in which way their care was provided. Each Sister had a detailed care plan which was reflective of their needs and had been reviewed at regular intervals. Staff were knowledgeable about the Sisters that they were supporting and provided personalised care. Assessments and care plans we looked at during the inspection reflected the detailed knowledge that staff had. Risks to the Sisters had been identified, assessed and measures had been put in place to ensure these were reduced and managed safely.
The Sisters received their prescribed medicines safely, from staff who had completed the required training and had their competency to do so assessed. Staff adhered to the provider's infection control policy and used the appropriate equipment and clothing, whenever required.
Staff had the necessary skills and knowledge to meet deliver the care required. The registered manager operated a system of training, supervision, appraisal and competency assessments, which enabled staff to provide good quality care.
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.
Staff consistently treated the Sisters with kindness and respect. They were supported to express their views about their care and their wishes were respected. Privacy and dignity were respected and promoted during the delivery of care.
There was a positive culture of person-centred, quality care throughout the service. Staff told us they enjoyed working here and that they were well supported by the management team. Staff felt valued and were committed to the service and the Sisters they were supporting.
The registered manager was dedicated to maintaining high standards and used the systems in place to drive effective quality assurance processes and continuous improvement within the service. No formal complaints had been raised at the service; however, there was a procedure in place should any concerns be raised.
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 9 May 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.