Inmind Community Support Services Limited provides personal care to people living in their own homes, some people are supported in supported living environments. Support can be provided to a variety of people including older and younger people and people who have a learning disability and or who are autistic. 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. Improvements had been made since the last inspection, risks to people were managed in a safe way and improvements had been made to ensure the service was effectively monitored. The assessment was started on 14 February 2024. One inspector undertook a site visit on 21 February 2024.
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Following short-notice departures of office and care staff, governance and call-monitoring systems broke down, leading to late or short calls, out-of-date care records and lapsed supervisions, with a breach of Regulation 17. The service remained safe in some areas (recruitment, medicines, infection control) but Safe and Well-led were both rated Requires Improvement.
Concerns (11)
criticalGovernance: “Systems and processes to ensure monitoring and oversight of the quality and safety of the service were not operating effectively. Audits and quality assurance checks did not identify the issues found on inspection.”
criticalStaffing levels: “The provider failed to ensure sufficient staff were available to deliver care to people at agreed times specified in their care plans.”
criticalMissed or late visits: “The lateness can vary up to 30 minutes. On one occasion it went up to an hour... Some carers are staying six or seven minutes then writing on their app that they have done everything.”
moderateCare planning: “Care plans and risk assessments did not always provide staff with the up to date information regarding people's needs.”
moderateRecord keeping: “Care records did not always hold the most up to date information regarding people and their care needs.”
moderateSupervision / appraisal: “Staff had not received supervision and their competencies had not been assessed for over 12 months.”
moderateStaff competency: “Staff had received training in how to support people with their medication but checks on their practice had not taken for over 12 months.”
moderateCommunication with families: “The provider did not have effective communication systems to ensure people could contact management to raise any concerns or discuss their packages of care.”
moderateComplaints handling: “Not all people using the service were confident their concerns would be dealt with... 'I have recently sent an email but have had no response, so communication is not the best.'”
moderateLeadership: “Due to staffing pressures, the registered manager was unable to effectively monitor call delivery, oversee staff supervisions and spot checks, review people's care, ensure care records were up to date.”
moderateSafeguarding: “the registered manager had failed to notify CQC of a safeguarding concern that had been bought to their attention. This was immediately rectified during the inspection.”
Strengths
· People felt safe when supported by staff in their own home and were supported by a consistent group of staff.
· Recruitment checks including DBS and references were completed to ensure staff were safe to work with people.
· Medicines were managed safely and audits were in place to identify errors or areas for action.
· Effective infection prevention and control measures were in place with plentiful PPE and COVID-19 testing.
· Staff felt supported by the registered manager who was open and transparent during the inspection.
Quality-Statement breakdown (9)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Working in partnership with othersRequires improvement