Updated 28 September 2023
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 2014.
Inspection team
This inspection was carried out by 2 inspectors.
Diversity Health and Social Care Limited is a domiciliary care agency. It provides personal care to people living in their own homes.
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 no registered manager in post, although the provider had appointed a new manager who was due to apply for registration with the Care Quality Commission (“CQC”).
Notice of inspection
This inspection was unannounced although we announced when we would be returning on the second day.
Inspection activity started on 14 June 2023 and ended on 31 July 2023. We requested a range of documents that were sent to us by the provider between 14 June 2023 and ended on 31 July 2023. We visited the office location on 14 and 16 June 2023 to see the acting manager and to review further records related to the service. We made telephone calls to people, their relatives and care staff between 16 June 2023 and 20 July 2023.
What we did before the inspection
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 reviewed information we had received about the service since the last inspection. This included any significant incidents that occurred at the service as well as concerns that had been reported to us anonymously.
We reviewed information from the local authority commissioning team and reviewed the previous inspection report. We used all this information to plan our inspection.
During the inspection
We reviewed a range of records related to 15 people’s care and support. This included people’s care plans, risk assessments, medicines records and 5 staff files in relation to recruitment and training. We reviewed records related to the management of the service, which included safeguarding incidents, quality assurance records, minutes of staff meetings and a range of policies and procedures.
We communicated with 20 staff members. This included the acting manager, a senior member of staff, office staff including the deputy manager and 15 care workers. We spoke with 15 people and 9 relatives.
We continued to seek clarification from the provider to validate evidence found after the inspection. We looked at further quality assurance records and correspondence with a range of professionals related to people’s care.
We provided feedback to the registered manager via email on 21 July 2023.