Sihara care is a domiciliary care agency registered to provide personal care to people in their own homes. The service provides support to people of all ages and different abilities. At the time of this assessment, they supported 50 people who received personal care. The Care Quality Commission (CQC) only inspect the service received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. We conducted this assessment to follow up on concerns we identified at the last inspection. These included breaches of Regulations relating to safe care and treatment and good governance. The last rating for this service was requires improvement (published 26 September 2022). At this assessment we found improvements had been made and the provider was no longer in breach of regulations. Assessment activity started on 15 November 2024 and ended on 29 November 2024. The manager in post was in the process of registering with the CQC as the registered manager for this service. We assessed quality statements from the safe, effective, responsive and well-led key questions. The overall rating for the service is good. People received care and support that met their individual needs. Saff had the training and information they needed to care for people effectively. Appropriate recruitment systems were in place. Systems were in place to help monitor and assess the quality of care and support provided.
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Sihara Care was rated Requires Improvement overall, with breaches of Regulation 12 (safe care and treatment) due to inadequate risk assessments and Regulation 17 (good governance) due to ineffective auditing systems. Caring was rated Good but care plans had not been reviewed since 2020, supervision records lacked detail, and there was no registered manager in post.
Concerns (12)
criticalCare planning: “one person was at risk of absence seizures, however there was not an appropriate risk assessment in place. Another person had a history of strokes, but there was no risk assessment in place”
criticalGovernance: “The current auditing systems in place were not robust enough to assess and improve the quality and safety of the services being provided to people.”
moderateCare planning: “we looked at a sample of care plans and noted that they had not been reviewed since 2020”
moderateRecord keeping: “the level of detail in each person's care records varied and information was not consistently recorded”
moderateLeadership: “At the time of the inspection there was not a registered manager in post.”
moderateStaff competency: “a number of staff had not completed medicines competency checks”
minorSupervision / appraisal: “the information documented in these were generic and there was a lack of detail as to what was discussed during these sessions”
minorStaff training: “The training matrix indicated that the majority of staff had not completed end of life training.”
minorOther: “there were instances where it was not clear who had provided these as referee details were limited. There was a lack of evidence to confirm that references had been verified”
minorEnd-of-life care: “Care plans did not evidence a discussion surrounding end of life wishes had been considered.”
minorCommunication with families: “It is difficult to contact them in an emergency, bad communication.”
minorMissed or late visits: “Sometimes they come late.”
Strengths
· Appropriate medicines management and administration processes were in place, with electronic MAR system and monthly audits
· People felt safe and were protected from abuse with effective safeguarding systems
· Effective infection prevention and control including COVID-19 measures with proper PPE use
· Kind, compassionate and respectful care from staff who maintained dignity and privacy
· Consistent care workers matched with people based on personality, cultural needs and language
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standardsGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies; supporting access to healthcareGood
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: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Provider plans and promotes person-centred, high-quality care; duty of candourGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood