We carried out our assessment of this service between 11 March 2025 and 17 March 2025. Freivan Support Services provides care and support to people living in a supported living settings, where they can live as independently as possible. People's care and housing are provided under separate contractual agreements. Accommodation is provided by a separate landlord. CQC does not regulate premises used for supported living. At the time of this assessment, the service was providing personal care to 9 people. The service also provides domiciliary care to people in their own homes. CQC only assesses where people receive personal care. This is help with tasks related to personal hygiene and eating. At the time of this assessment, the service was providing personal care to 2 people. We have assessed the service against ‘right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The service was able to fully demonstrate how they were meeting the underpinning principles of right support, right care and right culture. We had previously inspected this service in June 2022 when we had rated the safe, responsive and well led domains as requires improvement. We rated effective and caring as good. Overall, the service was rated requires improvement. During this inspection, we saw improvements had been made. This means that the services overall rating also improved and is now rated good. This was a planned assessment of all quality statements under the key questions of safe, responsive and well-led. We carried out the site visit on 13 March 2025. We gave the service 24 hours’ notice of the inspection. This was because we wanted to make sure someone would be available to support us with the assessment.
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Freivan Support Services received an overall 'Requires Improvement' rating on its first CQC inspection, with regulatory breaches identified under Regulation 12 (safe care and treatment) and Regulation 17 (good governance) due to inadequate risk recording and absent quality assurance audits. Caring and effective practice were rated Good, underpinned by respectful staff, multi-agency working and consent-compliant care, but weaknesses in care plan personalisation, staff training oversight and the absence of a registered manager remained significant concerns.
Concerns (10)
criticalGovernance: “The nominated individual told us they had not completed any audits; care plans, staff files or care notes had not been audited to ensure the quality of people's care.”
criticalRecord keeping: “Risks to people were not always recorded and information provided to staff did not always mitigate risks.”
moderateCare planning: “We also found information which had been copied and pasted from one person's care plan to another person's. This led to there being contradictory information about the person's personal care routine.”
moderateStaff training: “At the time of our inspection, the provider had not kept their systems up to date to effectively monitor staff training.”
moderateStaff competency: “There had been no observations of staff at the time of the inspection. This was not best practice.”
moderateInfection control: “They told us they had no systems in place to request or record staff testing, so were unable to demonstrate best practice in this area.”
moderatePerson-centred care: “Care plans were not always person centred... one person's care plan stated they had a lifelong health condition that affected their movement and co-ordination. This condition was not named until halfway through a section.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post.”
minorEnd-of-life care: “Care plans did not contain information about people's end of life wishes.”
minorCommunication with families: “The service recorded people had varied communication needs but these were not sufficiently detailed. Care plans used terms such as '[Person] can communicate through expressions and gestures' but did not provide further information.”
Strengths
· Staff were trained in safeguarding and there had been no safeguarding concerns at the time of inspection.
· People's needs were assessed before they began using the service in line with the law, including identification of protected characteristics and cultural needs.
· Staff worked with other agencies including social workers, occupational therapists and speech and language therapists.
· People's privacy, dignity and independence were respected and promoted, confirmed by relatives.
· Staff received one-to-one supervision and were able to raise concerns.
Quality-Statement breakdown (23)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: End of life care and supportRequires improvement
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
well-led: Promoting a positive culture; continuous learning and improving careRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: How the provider understands and acts on the duty of candourGood