Chapel And District Bespoke Care Limited

The service was first registered with the Care Quality Commission (CQC) on 14 February 2022. We carried out this inspection because the service had not yet been rated. This inspection was carried out by 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 care.
We gave the provider notice of our inspection because we needed to ensure the registered manager would be available to meet with the inspector at the provider’s office. At the time of this inspection, 38 people received the regulated activity of personal care.

A learning culture was evident and people felt they could raise any concerns and the staff and management would listen. Managers investigated incidents when these were raised. Staff understood and managed risks well. There were enough staff with the right skills, knowledge, and experience to meet people’s needs. Staff had received relevant training and understood their roles and responsibilities. Staff managed people’s prescribed medicines well.

People were involved in deciding how they received their care. People’s care plans and risk assessments were in place however, not always fully completed. Following our inspection the registered manager took measures to ensure all care plans were reviewed to ensure they were comprehensive and updated. They took account of people’s individual communication needs as well as their personal care and health care needs. Staff ensured an appropriate best interest decision making process was followed where people did not have the capacity to make decisions for themselves.

Staff treated people as individuals and protected their privacy and dignity. Staff explained how they involved people in their care and support to ensure this matched with their personal preferences and routines.

Governance systems were in place, however some audits were not completed as frequently or thoroughly as required, which meant their application sometimes lacked consistency. This had not resulted in harm however, this meant some records did not fully reflect people’s current care and required further personalisation. The provider was aware of the improvements needed and took immediate action when issues were identified to address these shortfalls.

Workforce systems, including rota’s, training records, recruitment checks and performance management processes, were in place and up to date. Supervisions and team meetings had taken place. Communication with people who used the service and staff was generally positive.

The registered manager was knowledgeable, treated staff fairly and respected their wellbeing. The provider had a whistle blowing policy and staff were able to raise concerns, although staff feedback indicated they did not always feel listened to. Leaders collaborated with community healthcare teams to ensure people received consistent and effective healthcare support. There was a culture of continuous improvement and of learning lessons from incidents to help reduce recurrences.