Background to this inspection
Updated
17 June 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
The inspection was carried out by one inspector.
Service and service type
This service is a domiciliary care agency providing support to people living in shared accommodation so they can live as independently as possible.
The service had a manager registered with the Care Quality Commission. However, they were only working a very few hours and planned to resign from their role. An application had been submitted to us for a new manager to be registered to provide the regulated activity and manage the service. This means the registered manager 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
This inspection was announced. We gave the service 24 hours’ notice of the inspection. This was because we needed to be sure that the provider or registered manager would be available to meet with us. Inspection activity started on 10 May 2021 and ended on 28 May 2021. We visited the office location on 12 May 2021.
What we did before the inspection
We reviewed all the 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. The provider was not asked to complete a provider information return prior to this inspection. 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 took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with two people who used the service and two family members about their views of the care provided. We spoke with the director, manager and two members of staff. We also had feedback from a further five members of staff via email. We spoke with two health and social care professionals and had email feedback from another three about their views of the service.
We reviewed a range of records. This included three people’s care records and medicine records. We looked at two staff files in relation to recruitment and training. 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 and further information was sent to us as requested.
Updated
17 June 2021
About the service
Southways Group Ltd provides care and support to people living in specialist housing. At the time of the inspection, people lived in an adapted household accommodation in a shared site or building. The accommodation is rented and is the occupant's own home. People's care and housing are provided under separate contractual agreements. CQC does not regulate the premises used for this type of housing; this inspection looked at people's personal care and support service. At the time of the inspection five people were being supported with personal care.
People’s experience of using this service and what we found
The previous inspection in December 2019 found that standards relating to the quality and safety of the service needed to be improved. The provider had not always recorded areas of risk; safeguarding concerns were not raised with the appropriate bodies; the way people's medicines were managed needed to improve and staff had not received all the training they required, especially in relation to mental capacity and infection control. Care plans did not contain all relevant information about people’s needs and had not been reviewed to ensure their care and support was relevant and up to date. Accidents and incidents monitoring, governance systems and quality audits were not robust enough to ensure the management of the service was effective.
Improvements had been made throughout the service.
People who were able to talk with us over the telephone told us they were safe using the service. Family members told us their relatives were being cared for by staff who knew them well. Health and social care professionals thought the service had improved and people had better outcomes.
People were cared for by staff who were reliable and consistent. Rotas were organised in a way which meant people saw the same team of staff so that relationships were developed and maintained.
Staff had a good understanding of safeguarding processes to keep people safe and how to report any concerns. Staff understood and were aware of their responsibilities to raise concerns and report all incidents. People were supported with their medicines when they needed them. We were assured the service met good infection prevention and control guidelines and personal protective equipment (PPE) was readily available. There were enough staff to provide care and support to people and staff had been suitably recruited to their role.
Staff were aware of people’s needs and supported them to manage risks to their safety whilst supporting them to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.
People’s needs had been assessed and reviewed. Care plans contained information about people’s needs and ways in which they should be met. This included their routines, preferences, and more recently, gathering information about their protected characteristics, culture and lifestyle.
Staff confirmed they had received training which gave them the knowledge and skills to carry out their roles. Spot checks were carried out to monitor staff practice and ensure they were working safely. People had good support with their meals. People were supported to access healthcare where needed. Staff worked very well with other professionals to ensure people’s healthcare needs were met
Staff treated people with dignity, respect, kindness and promoted their independence. Staff recorded information about people in a respectful way. Obtaining people’s views as to their end of life wishes was ongoing and information was being captured at their pace. The manager was seeking support and training for staff in order to explore with people their wishes and choices.
Systems had improved to assess, manage and monitor the oversight and quality of the service. Complaints were investigated and responded to. Where things had gone wrong, the manager was open and transparent with people, and their relatives and used their feedback to improve the service.
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 requires improvement (published 7 January 2020). Where we identified breaches of the regulations and made recommendations for the service to improve, the provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvement had been made and the provider was no longer in breach of the regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
Follow up
We will continue to monitor information we receive about the service. If we receive any concerning information we may inspect sooner.