Background to this inspection
Updated
29 November 2022
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 2008.
Inspection team
The inspection team comprised of two inspectors.
Service and service type
This service provides care and support to people living in a ‘supported living’ setting, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.
During the course of the inspection the manager became the registered manager for the service.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.
Inspection activity started on 26 July 2022 and ended on 8 August 2022. We visited the location’s office on 26 July 2022.
What we did before the inspection
We reviewed information we had received since the service was registered with us. We requested feedback from the local authority. 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 used all this information to plan our inspection.
During the inspection
We spoke with one person using the service. We spoke with four members of staff including the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records. This included one person’s care and medication records. We looked at two staff files in relation to the recruitment and supervision of staff. A variety of records relating to the management of the service, including policies and procedures were reviewed.
Updated
29 November 2022
About the service
Creative Lifestyles Midlands Limited is a community based service that provides personal care to people living in their own homes in a supported living setting. At the time of the inspection one person was in receipt of the regulated activity personal care. The service is also registered to provide domiciliary care, although this type of service was not being provided at the time of the inspection.
Creative Lifestyles Midlands Limited is made up of seven single bedrooms. There were shared living areas which include the kitchen, lounge, bathrooms and garden. There was a separate office area for staff.
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.
People’s experience of using this service and what we found
People had not always had all of the risks associated with their care fully mitigated. Reviews of care records had not been consistently effective at identifying where information was missing from peoples care plans.
Systems around ensuring consistent recruitment was carried out needed improving. Whilst individual incidents were reviewed there was no analysis of incidents across the service which may have identified themes and trends.
The provider’s systems to monitor the quality and safety of the service had not been effective at identifying the concerns we found at this inspection. There had been a number of managers at the service since registration. The current registered manager showed a willingness and drive to make the necessary improvements within the service.
People were supported by staff who understood how to recognise and escalate safeguarding concerns should they have any. People received safe support with their medicines and checks were carried out on staff to ensure they were competent to administer medications.
People were supported to access appropriate healthcare and any concerns relating to changes in people’s healthcare needs were escalated appropriately.
People received meals that they enjoyed. Improvement was required around the directions provided to staff around monitoring fluid intake and in providing staff with catheter care training.
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.
People had information available to them in an accessible format to aid their understanding of key topics.
There were systems in place that enabled people to complain about their care should they need to.
Staff received an induction and training to support people. Staff felt supported in their roles and were able to make suggestions for improvements within the service.
At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.
For more details, please see the full report for Creating Lifestyles Midlands Limited which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 25 November 2020 and this is the first inspection.
Why we inspected
This is a newly registered service and we needed to inspect and rate the service.
Enforcement
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 a breach in relation to how the safety and quality of the service was monitored at this inspection.
Please see the action we have told the provider to take at the end of this report.
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.