Background to this inspection
Updated
30 September 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 consisted of one 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 service.
Service and service type
Eleven Sisters Healthcare Ltd is a domiciliary care agency. It provides personal care to people living in their own homes.
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 provider three days’ notice because we needed to ensure somebody would be available to assist us with the inspection and to review records before the site visit.
Inspection activity started on 18 August 2021 and ended on 2 September 2021. We requested a range of documents related to people’s care that were sent to us by the registered manager between 18 and 23 August 2021. We visited the office location on 19 August 2021 to see the management team and to review further records related to the service. We made calls to people and their relatives between 19 and 20 August 2021 and calls to care staff between 23 and 27 August 2021.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. This included any significant incidents that occurred at the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We also contacted the local authority commissioning team and reviewed the previous inspection report. We used all of this information to plan our inspection.
During the inspection
We reviewed a range of records related to five people’s care and support. This included people’s care plans, risk assessments, medicines records and three staff files in relation to recruitment, training and supervision. We also reviewed records related to the management of the service, which included quality assurance checks, policies and procedures, incidents and accidents and minutes of team meetings.
We spoke with seven staff members. This included the registered manager, two care coordinators and four care workers.
We made calls to 14 people and spoke with seven relatives. The majority of people we called were unable to fully communicate with us over the telephone.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at electronic call monitoring (ECM) data for two people, recruitment records and further training and supervision records. We also spoke with two health and social care professionals who had experience of working with the service.
We provided formal feedback to the registered manager on 2 September 2021 over the telephone and via email.
Updated
30 September 2021
About the service
Eleven Sisters Healthcare Ltd is a domiciliary care agency. It provides personal care to people living in their own homes. It provides a service to older people, some living with dementia. It also supports people with more complex care needs who require regular monitoring and overnight support, including some of whom were receiving end of life care.
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 the inspection the provider was supporting 15 people in the London Borough of Tower Hamlets.
People’s experience of using this service and what we found
Relatives praised the kind and compassionate attitude of their care workers and how they knew them well and kept them safe. One relative said, “I could not ask for better. Since being in this country I am so happy with the excellent care we have received. A big thank you to all the carers and the office.”
People received person-centred care and records had detailed information for care workers to understand their needs and how they liked to be supported. New staff were introduced to people and their relatives and carried out shadowing and observations before they started working with them.
Staff monitored people’s health and wellbeing and reported any changes or concerns. Where there were complex care needs, staff worked closely with the relevant health and social care professionals for additional support and guidance.
Relatives and health and social care professionals complimented the management of the service and felt confident and reassured with the level of care provided. The registered manager and support team were responsive and had regular communication with people and their relatives about the support they received.
Relatives felt comfortable contacting the registered manager if they needed to discuss any aspects of the service and were confident they would be listened to. People and their relatives were given opportunities to discuss their care and monitoring was in place to see if any improvements could be made.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.
People were supported by a staff team who felt valued and respected and were positive about their inclusive working environment. Staff felt the provider ensured their safety and wellbeing whilst at work and listened to any issues or concerns.
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 inspected but not rated (published 9 December 2020).
The service was registered with us on 24 October 2017 but had been in periods of dormancy until the first inspection on 11 November 2020.
Due to the COVID-19 pandemic our ways of inspecting were being regularly reviewed and at the time of the last inspection we were carrying out focused inspections, where we were unable to rate the service. The inspection reviewed the key questions of Safe and Well-led only.
Why we inspected
We carried out this inspection following a routine review of information we held about this service. Our intelligence indicated there may be a higher level of risk at this service due to the length of time it had been registered and not rated.
Follow up
We will continue to monitor information we receive about the service. If we receive any concerning information we may return to inspect.