Excel Care (UK) Ltd

Excel Care (UK) Ltd is a domiciliary care agency. It provides a range of services, including personal care, medication support, meal preparation and supports people to access the community and remain as independent as possible whilst living in their own home. The service was providing personal care for 10 people in total. The service also opened a new supported living service in June 2019, providing care and accommodation to three people with a mental health need.

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.

We visited the supported living service and found the three people living there did not require support with their personal care, therefore we did not inspect the supported living service. However, during our visit we identified potential fire hazards connected to the environment. Shortly after the inspection the Greater Manchester and Fire Rescue Service (GMFRS) visited the service and made several recommendations. One of these included the installation of fire doors on the kitchen and escape routes from the ground and first floor. The GMFRS were working with the service to ensure their recommendations were acted upon.

People’s experience of using this service and what we found

The registered manager had established a number of quality assurance systems to monitor the quality and safety of the service. There was evidence of improvement and learning from any actions identified.

People were safe and protected from abuse. People were supported by a small team of staff who they knew. The registered manager had introduced safer recruitment systems to ensure new staff were suitable to work in people's homes.

People received the support they needed to take their medicines. Provider oversight of people’s medicines had improved with the introduction of new auditing systems. Staff were trained in how to provide people's care in a safe way.

Staff treated people in a kind and caring way. People valued the service and the support staff provided. The staff treated people with respect and helped them to maintain their independence and dignity.

The registered manager had updated people's care plans, which we found were person-centred and outcome focussed. The new care plans provided staff with the information they needed to provide care and support in a way that met people's needs and preferences. There was evidence that care plans were reviewed regularly or as people's needs changed.

People knew how to make a complaint. There was an effective complaints process in place to deal with any complaints that might be raised in the future.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (report published 8 May 2019) and there were two breaches of regulations. We served a warning noticed for Regulation 17. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on our current methodology.

Excel Care (UK) Ltd is a domiciliary care service which is registered to provide personal care to people living in their own homes. At the time of inspection, 13 people were receiving care and support services.

People's experience of using this service:

The service had recently recruited a new manager who was in the process of registering to become the registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was a lack of managerial oversight and scrutiny of the service. Significant improvements were required to ensure effective quality assurance systems and processes were in place and embedded to assess, monitor and improve the quality of the service.

People who received care from Excel Care (UK) Ltd told us they felt safe and supported by staff who visited them. Staff were punctual and consistent at carrying out visits with people in a person-centred manner.

People were supported to continue living at home in a way that enabled them to be as independent as possible.

The manager and provider had not ensured that certain areas of the service were always safe. We found that one person’s risk assessments in respect of moving and handling had not been completed, which potentially put the person at risk of receiving unsafe care.

Recruitment procedures were unsafe. Staff had been recruited without thorough checks being completed. Inconsistencies were found in respect of gaps in employment not being followed up on and references not being correctly obtained.

Not all people's care plans were person-centred. Care records documenting people’s preferences and medical histories were not always captured. We have made a recommendation that the provider seeks guidance and advice from a reputable source, in relation to personalised care planning.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA). We found the service ensured staff received training in respect of the MCA, however we found consent forms were signed by family members of the people who lack the appropriate authority.

People and relatives described staff as caring and kind towards them. Staff were approachable and friendly with people they cared for and knew them well.

Staff enjoyed working at the service and said the manager and team leaders were approachable.

Rating at last inspection:

At the last inspection we rated Excel Care (UK) Ltd as 'Requires Improvement' (report published 18 May 2018).

Why we inspected:

At the previous Inspection, we found one breach of regulation 17 and we issued a requirement notice. This was a comprehensive inspection to check their progress and if they had now met the regulations.

Enforcement:

Full information about CQC's regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Not everyone using Excel Care receives the regulated activity; the Care Quality Commission (CQC) only inspects the service being 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.

At the last comprehensive inspection in July 2017, we judged that improvements were required in delivering a safe, responsive and well-led service.

We found breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not carried out all required recruitment checks to make sure staff were suitable to work with people who used the service. The provider had not ensured people’s risk assessments contained specific guidance about what actions needed to be taken to reduce or remove the risk. The provider had not established an effective system that enabled them to ensure compliance with the requirements of the fundamental standards.

We took enforcement after the last inspection to cancel the registered manager’s registration, and this concluded in December 2017.

The service did not have a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of this inspection the provider was in the process of registering the service manager to become the registered manager.

At this inspection we found there had been improvements, which were sufficient for the service to be rated as requires improvement overall and good in caring and responsive with no inadequate domains. This meant the service could come out of special measures. However, we found further improvements were required to ensure the providers auditing systems evidenced how they were managing late visits and the auditing of Medication Administration Records (MARs).

Improvements had been made to ensure that most people were visited by the same staff so they could build trusting relationships with them. The staff that visited people were kind, caring and compassionate. They treated people with dignity and respect and tried to help them be as independent as they could.

People told us they received consistent carers that attended within thirty minutes either side of the allocated timeframes. People told us they had not experienced any missed visits. People were satisfied with the consistency of care and told us they had regular care staff supporting them.

We examined staff training records which demonstrated that training relevant to their job roles was provided. However, new staff were not supported through the care certificate or equivalent. This meant we could not be fully assured new staff had received a robust induction in health and social care. Staff had received regular supervision and an annual appraisal.

People received their medicines on time and in a safe way. However, we have made a recommendation the provider introduces an individual medicines risk assessment as part of people’s pre-admission to the service in line with ‘Managing medicines for adults receiving social care in the community’ guidance.

People were kept safe by staff who had an understanding of their responsibilities with regards to protecting people from harm or possible abuse. There were sufficient numbers of staff employed at the service and staff had been recruited appropriately with pre-employment checks completed before staff commenced working at the service.

The provider had a clear understanding of the Mental Capacity Act 2005. They were knowledgeable about protecting legal rights of people who did not have the capacity to make decisions for themselves. The service acted in accordance with legal requirements to support people who may lack capacity to make their own decisions.

There was a complaints policy and procedure in place and we saw that complaints had been recorded and investigated with an outcome recorded.

Staff supervisions and appraisals had been completed in line with the provider's policy and procedures. Staff meetings had been held regularly to support staff and gain their feedback to improve the service.

People received a service that was based on their needs and wishes.. Care plans were personalised and contained detailed information about the support people needed.

There had not been any accidents, incidents or complaints. Policies and procedures were in place which would ensure any accidents, incidents or complaints would be effectively dealt with in a timely way.

Satisfaction surveys had been completed by people and their relatives and the majority gave positive feedback. However, we found these surveys had not been analysed to evidence any changes as a result of the feedback

There were quality monitoring systems in place; these included satisfaction surveys, spot checks and internal audits. However further improvement was required to ensure people’s medicines records were audited and analysed to ensure people received their medicines safely. Furthermore, the provider had not ensured late calls were analysed to improve the timings of scheduled calls. The provider acknowledged that this was an area which required further development and steps were in place to address this as a matter of priority.

This is the fourth consecutive inspection that the service has been rated Requires Improvement. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The previous inspection took place in November 2016 where three breaches of the Health and Social Care Act 2008 were identified. This inspection was carried out to check on the improvement actions identified in the provider's representations following our inspection in May 2016 where enforcement action was taken and a Notice of Proposal (NoP) was issued. The inspection in November 2016 found that there was not enough improvement to take the provider out of special measures and the service was rated Inadequate in the well led domain and overall ‘Requires Improvement’

This inspection was carried out to check on the improvement actions identified when we inspected in November 2016. We found that there were continuing breaches of the Health and Social Care Act 2008 and insufficient improvements made.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.”

The service had a registered manager who had been in post since March 2014. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Recruitment processes needed to be strengthened to help ensure suitable candidates were employed to work at the service.

Risk assessments in place were not sufficiently detailed to guide staff on how to keep a person safe. We found an example where risks had been identified but no assessment had been done to mitigate these. This meant people were not protected from harm as care staff had limited or no guidance to manage these risks safely.

People told us they had not experienced many missed visits. They said care staff were occasionally late but that the quality of care provided had not been affected. They told us the care staff’s timekeeping had improved. Missed and late visits meant however that people had either not received care and support needed or had not received care at times that suited them. People were satisfied with the consistency of care and told us they had regular care staff supporting them.

Where required, people were supported to take their medication safely. Following our inspection in November 2016, care staff had received required medication administration training. This should help to ensure that people received their medication safely.

Staff were aware of safeguarding principles and knew what to do in the event they suspected abuse was taking place. We concluded staff had sufficient knowledge and information to help ensure people were kept safe from harm.

People and relatives told us care staff had good hygiene practices and wore personal protective equipment when carrying out their duties. This practice helped to ensure people were protected from the risk of infection.

There was a system in place for recording accidents and incidents. This helped to ensure the service took appropriate action to keep people safe from harm.

People and their relatives told us care staff were effective and well trained, and always sought their consent before undertaking any task. The registered manager and care staff we spoke with demonstrated a good understanding and knowledge of the Mental Capacity Act (MCA) and we saw there was a policy in place to guide practice. We were satisfied the service was working within the principles of the MCA.

Staff had an induction and received mandatory training in key areas such as safeguarding, manual handling and infection control prior to starting their role. Staff received regular supervisions and appraisals to help ensure they received the necessary support to carry out their roles. This meant staff had suitable knowledge and skills and received continuous support to function effectively in their caring role.

People were supported and encouraged to make healthy eating and drinking choices. This should help people to maintain a balanced diet and support their wellbeing.

People’s access to health care professionals and medical attention was facilitated, if required. This meant people were supported to receive the right health care when they needed.

People and their relatives told us they received caring and compassionate support. Care staff were friendly yet professional and some people had developed good relationships with them.

People and relatives told us they had been involved in the care planning process. This meant that people and their relatives, where appropriate, were included in making decisions about the care they received.

People were treated with dignity and respect and their independence was encouraged according to their abilities. This helped to promote people’s wellbeing.

People and their relatives found the service was responsive to their needs.

Initial assessments were carried out to help ensure the service was able to meet the specific needs of the person.

People knew the complaints procedure though no one had made a formal complaint. There was a complaints policy in place and we saw evidence the service adequately dealt with verbal concerns raised by people they supported.

The service had recently implemented quality surveys to find out what people thought about the service they received. Not everyone we spoke with had been surveyed and the results of completed surveys had not been collated or fully analysed. This meant that while the provider had sought people’s feedback on the care they received, they had not demonstrated to us how this information would be used to improve the quality of care provided.

Care plans contained information about the support people required at each visit but not all care plans contained adequate guidance to help ensure staff carried out the tasks responsively. This meant people may not receive care that was responsive to their specific needs. Care staff knew what person centred care meant and told us they always looked at people’s care records before undertaking tasks.

People and relatives told us they were happy with the services of Excel Care. Staff said they felt supported by the management team and that the registered manager was approachable and fair.

The service did not display the current rating which was ‘Requires Improvement’ at its office and on its website. This was a legal requirement.

We found that quality assurance processes in place were not robust and did not give the registered manager and provider effective oversight of the quality and safety of service. This meant that people’s care and support were not adequately monitored to ensure their safety and wellbeing.

Staff meetings took place regularly and gave care staff the opportunity to discuss their work with each other and the management team. This meant staff received adequate support which helped them to provide people with effective care.

We found four breaches in the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, fit and proper persons, governance systems and failure to display.

Excel Care (UK) Limited is a domiciliary care agency which works from an office in Moston. It is a ground floor office and accessible to the public. On our visit the agency office was closed. We rang the office telephone number and this was answered by the provider who came to open the office.

The provider of this service was also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The previous inspection took place in May 2016 where six breaches of the Health and Social Care Act 2008 were identified. The provider was placed into special measures by CQC. We took enforcement action and issued a Notice of Proposal (NoP) to cancel the provider’s registration. The provider made representations to the Commission (CQC) in respect of the NoP. This inspection was carried out to check on the improvement actions identified in the provider’s representations.

This inspection found that there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

People felt safe supported by Excel Care. Staff knew people’s needs and there were enough staff to support them effectively.

Medicines were administered by staff. However they had not received appropriate training and did not record the medicines administered. The provider manager said staff only prompted people with their medicines; however this was not the case. This had been highlighted in our last inspection report.

A new recruitment procedure had been written which should help to ensure all the relevant pre-employment checks were made. No new staff had been recruited since our last inspection and we will check how the procedure has been used at our next inspection.

The provider manager clearly explained how they would investigate any safeguarding concern or complaint. However the safeguarding management system and complaints procedure the provider manager said were in place in their representations to CQC’s NoP were still being written.

Staff sought consent from people before providing care or support. People thought not to have capacity to consent to their care and support had been referred to the local authority by the provider manager for a capacity assessment to be completed. However not all care staff understood the requirements of the Mental Capacity Act (MCA) as they told us that everyone they supported had capacity. People had not signed their care and support plans to show they agreed with them. We have made a recommendation about following best practice guidelines to ensure people or their legally authorised representatives sign the care plans.

The service used a new computer based system, called PASS, to record care plans. Risk assessments had improved and were personalised to each individual the service supported.

We found care plans were not up to date. Some included information that was no longer relevant and tasks for staff to complete that were no longer needed. People and relatives told us of information that had not been included in the care plans. There was no evidence that the care plans had been reviewed with people or their relatives to ensure they were an accurate reflection of people’s needs and the tasks staff were to undertake.

Staff recorded daily notes and a record of the tasks they had undertaken directly into the PASS computer system via their mobile phones. However the system only updated when the staff mobile phones were connected to the internet. Staff used their own mobile phones and some staff members did not have roaming access to the internet and were only connected when they had a Wi-Fi internet access. This meant the records may not have been updated when the afternoon visits were made and so staff would not know what had been completed in the morning visits.

Staff received other training appropriate to their role and said they felt well supported by the provider manager. Spot checks were completed to observe staff providing support.

Quality audits for care plans, medicines, risk assessments and daily logs were not completed by the provider manager. This meant any issues were not being identified and so actions to make improvements could not be implemented.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Two of the breaches were continued breaches from the previous inspection in May 2016. You can see what action we have taken at the back of the full version of this report.

Excel Care (UK) Limited is a care agency which works from an office in Moston. It is a ground floor office and accessible to the public. However we found that on two occasions when we visited, the agency was shut . On the first occasion we rang, the phone was not answered and there was no answer machine facility. On the second visit we rang the number again and this time the provider answered and came to open the office.

The provider of this service was also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special Measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspecting again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate in any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

People felt safe and supported by the care staff, however when safeguarding concerns had been raised, these had not always been investigated and recorded appropriately.

People were well cared for and there were currently enough staff to support them effectively. The staff were knowledgeable about the needs of the people and knew how to spot signs of abuse. The recruitment process was not robust as sufficient checks had not been implemented prior to staff commencing work.

Staff sought consent from people before providing care or support. The ability of people to make decisions was not always assessed in line with legal requirements to ensure their liberty was not restricted unlawfully, such as locking a person in their property.

Risk assessments were not always up to date. Care plans were not written with the involvement of the person or their families. People had not been supported to be involved in identifying their support needs. Pre-assessments that included people’s likes and preferences had not been completed, but staff knew the people well.

Medicines were not administered safely as staff had not received appropriate training to support this task. Where people were supported to take their medicines, staff were not signing to say this had happened, which could have resulted in medicines being given twice.

Staff had completed training appropriate to their role, however one staff member had completed eleven of the training sessions on the same day. Staff were observed as being kind and caring, and treated people with dignity and respect. They spoke to people with respect. There was an open, trusting relationship between the people and staff, which showed that staff knew people well.

People and their relatives told us they had been asked for feedback about the service they received but there was no record of what actions had been taken to address any identified concerns. There was an open and transparent culture which was promoted amongst the staff team.

Complaints which were received were not recorded formally and there was no accident and incident log completed.

Policies and procedures were out of date and were not being followed. There was no evidence of quality assurance checks or audits being completed apart from on daily records. Even though audits on daily records were being completed, there was no action plan from the findings.

We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.

On this visit, we checked that the provider had taken the action necessary. We did not speak with any service users on this visit.

We found that the provider had improved their processes and they were now compliant in the outcomes relating to staff recruitment, assessing and monitoring the quality of the service and record keeping. We have made some comments which the provider may wish to note in our report.

We found that people were involved in their care and were treated with dignity. We found that the care people received was of a generally good standard. The provider had proper arrangements in place to keep people safe and there were sufficient staff on duty to meet people's needs.

We found that the provider did not mange people's individual risks properly. We saw that the provider did not collect all necessary information about people before employing them. We found that records were not always maintained appropriately.