Welcome Home

Welcome Home is registered with the Care Quality Commission as a residential care home and a domiciliary care agency.

The residential care home provides the regulated activity of personal care and accommodation for up to five adults with a learning disability. At the time of the inspection there were five people using the service. People had complex care needs, including learning disabilities, autism and physical health needs. Most people had limited verbal communication so were unable to provide feedback by speaking to us directly.

The community based domiciliary care agency delivered personal care to 82 people in their own homes. This included older people, people with dementia, physical disabilities and learning disabilities. 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.

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

People and relatives were positive about the quality of the service. Comments from people included, “I feel perfectly safe with the ladies (carers). I need help and they do that well” and “The staff are very bright and happy with me. I am happy to see them each day and they know my needs.” A relative told us, “My relative is just happy. That to me is everything. It makes me feel settled knowing they are well cared for.”

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: Staff were working towards consistency in supporting people to make decisions following best practice in decision-making. Staff worked with people to plan for when they experienced periods of distress so that their freedoms were restricted only if there was no alternative.

People were supported by a regular team of staff who knew them well, which promoted continuity of care.

People were involved in personalising their rooms so these were decorated to their taste and contained things that were important to them. Staff enabled people to access specialist health and social care support in the community. Staff supported people with their medicines in a way that achieved the best possible health outcome.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care: People’s needs and preferences had been assessed prior to receiving a service. People received kind and compassionate care from staff who understood and responded to people’s individual needs.

People who had individual ways of communicating, using body language and sounds, could interact comfortably with staff and others involved in their care and support because staff had the necessary skills to understand them.

There were enough appropriately skilled staff to meet people’s needs and keep them safe. Environmental risk assessments identified and reduced any risks to people and staff. Where appropriate, staff encouraged and enabled people to take positive risks. Staff understood how to protect people from poor care and abuse.

Right Culture: People benefitted from the open and positive culture of the service where the management team was approachable and listened and responded to people’s views. Quality assurance and monitoring systems were used to identify shortfalls and improve the service for the people who used it.

People received good quality care, support and treatment because trained staff and specialists could meet their needs and wishes. People were supported to maintain good health, were supported with their medicines and had accessed healthcare services when needed. Staff prepared food and drink to meet people’s dietary needs and requirements.

People were supported by staff who understood best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. This meant people received compassionate and empowering care that was tailored to their needs. People received consistent care from staff who knew them well. People and those important to them were involved in planning their care.

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 (published 25 May 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Welcome Home is registered with CQC to provide two services: A residential care home and a community based domiciliary care agency which delivers personal care to people in their own homes.

The care home provides accommodation, care and support to up to five adults with a learning disability. Four people were living in the service at the time of our inspection. People had complex care needs, including learning disabilities, autism and physical health needs such as epilepsy. People had limited verbal communication so were unable to provide feedback by speaking to us directly.

The care agency was providing personal care to approximately 45 people at the time of our inspection. The care agency is usually run from an office within the grounds of the care home with a separate staffing team. However, during the COVID-19 pandemic, the provider had arranged for the agency office staff to work from home most days of the week, to reduce the risk of infection. 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.

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

People could be assured the provider and registered manager were now making, maintaining and sustaining improvements to both services provided. Although some further improvement needed to be made and some work was still in progress, positive developments had been made and the feedback we received from people and relatives had improved.

People using the care agency were now receiving safer care and support. Individual risks had been identified and recorded, although some further work was needed to make sure this was maintained. Improvements in relation to people’s safe care in the care home had continued.

Some people and relatives were at times unhappy with the timing of their care visits as they told us staff sometimes turned up late or cancelled their visit. However, others did not experience this. We identified this as an area that continued to need some improvement.

Staffing levels in the care agency had improved, staff told us they now had more time to travel between visits and this meant they had more time to spend with people. Recruitment of new staff continued to be managed safely.

People using the care agency now received their medicines safely. Safe management of medicines continued in the care home. Infection control procedures had improved in the care home since our targeted infection control inspection in December 2020. People could now be assured safe processes were in place.

Following our recommendation at the last inspection, improvements had been made to the recording and follow up of complaints received in the care agency. People could now be assured they would receive a written response to their complaint.

Monitoring of quality and safety had improved in both services and the provider and registered manager had better oversight. There continued to be elements of quality monitoring that needed to improve further but positive developments had been made. The provider and registered manager needed the opportunity to show they could embed and sustain improvements as the service had a long history of CQC ratings below good.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Improvements had been made to the premises and furnishings in the care home since the last inspection, although this work continued to be in progress. Servicing of equipment and systems such as electrical and gas safety were completed regularly as required. People using the care agency felt safe with staff. They thought staff were knowledgeable and knew them well.

People and their relatives said the staff in the care home and the care agency were caring and supported them well. The relatives of people living in the care home described their loved ones as very happy. They confirmed they would know by their body language or verbal communication if they weren’t happy. One relative said, “It really is (their) home.” Staff kept relatives up to date with information about their loved ones. People living in the care home had been able to keep in touch with their loved ones through telephone and video calls and socially distanced visiting when government guidance allowed.

A person-centred approach was evident in both services. Staff knew people well and supported them with dignity and respect. People were encouraged to be involved in making decisions about their care using their own communication methods when they were not able to share verbally.

People were supported to access health care when needed to support their health and well-being. Staff helped people living in the care home to maintain a healthy and well-balanced diet. People living in their own homes were supported by care agency staff with their meal preparation if they needed this.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

This service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. Although people had limited capacity to make complex decisions, staff knew people well and supported them to make choices on a day to day basis by understanding their individual communication methods. The location of the service was not central to community resources however, people had been supported to acquire their own individual car to enable their independence in getting out and about. There was an open culture that put people at the heart of the service.

Right support:

• The model of care and setting maximised people’s choice, control and independence.

Right care:

• The care was person-centred and promoted people’s dignity, privacy and human rights.

Right culture:

• The ethos, values, attitudes and behaviours of leaders and care staff ensured people using the service led confident, inclusive and empowered lives.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 February 2020) and there were three breaches of regulation. We met with the provider after the last inspection to discuss what they would do and by when to improve. We stepped back from taking enforcement action after the last inspection as a proportionate response to the unfolding COVID-19 pandemic. At this inspection we found improvements had been made. This service has been rated requires improvement for the last seven consecutive inspections, however, many improvements had been made at this inspection and the provider was no longer in breach of regulation.

This service has been in Special Measures since 22 February 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating and to check the provider had taken action to make improvements following the last inspection. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

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

The care home provides accommodation, care and support to up to five adults with a learning disability. Four people were living in the service at the time of our inspection. People had complex care needs, including learning disabilities, autism and physical health needs such as epilepsy and diabetes. People had limited verbal communication so were unable to speak directly to us.

We found the following examples of good practice.

The service was generally clean and the domestic cleaner carried out deep cleaning in communal areas.

Staff supported people well to socially distance and isolate in their rooms by spending more one to one time providing activities.

The service had enough personal protective equipment (PPE) to meet current and future demand. Staff were using PPE correctly and in line with current guidance.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively. We found evidence that the provider needs to make improvement and took enforcement action against the provider and registered manager.

Further information is in the detailed findings below, including the regulatory action we have taken.

Welcome Home is registered with CQC to provide two services: A residential care home and a community based domiciliary care agency which delivers personal care to people in their own homes.

The care home provides accommodation, care and support to up to five adults with a learning disability. Five people were living in the service at the time of our inspection. People had complex care needs, including learning disabilities, autism and physical health needs such as epilepsy and diabetes. People had limited verbal communication so were unable to speak directly to us.

The service had not been developed and designed fully in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. The service did not consistently apply the principles and values the principles and values of Registering the Right Support and other best practice guidance. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them. People’s support did not always focus on them having as many opportunities as possible for them to gain new skills and experiences. Staff had started planning to find new interests and experiences for people to try to improve their choices.

The care agency was providing personal care to approximately 43 people at the time of our inspection, which was approximately the same number of people as at our last inspection. The care agency is run from an office within the grounds of the care home with a separate staffing team. The provider also provided care and support through the care agency to four people with a learning disability living in a 'supported living' setting in one property, so that they can live as independently as possible in their own home. 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.

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

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

The service people received was not always safe although clear improvements had been made in some areas. Some individual risks had not been identified, so management plans to prevent harm had not been completed for people using the care agency for support in their own home. However, in practice, staff did know people well and were aware of risks and how to keep people safe. Improvements had been made to the management of risk in the care home, however, an isolated incident of a potential infection control risk had not been managed in a quick and timely way.

People using the care agency and their relatives, told us time keeping was an issue with many of their care visits. They also reported that sometimes only one staff member turned up when there should be two staff. People and staff said they thought the care agency was short staffed. The records we looked at reinforced what we had been told. Although people said staff did stay the full allocated time, the records kept on the electronic recording system did not reflect this. There were no concerns with staffing levels in the care home.

People’s medicines were not always managed well by the care agency. Guidance for staff was not always in place and processes to assist people to order their medicines in a timely way was not always effective. People’s medicines were managed well in the care home.

Systems in place to monitor the electronic records kept by care agency staff supporting people in their own homes were not effective. Therefore, improvements to time keeping and staff record keeping were not addressed in a timely way. People and their relatives had mixed views about the management of the care agency as their telephone calls to the office were not always answered or staff did not always return their calls. Auditing processes to check the quality and safety of the service had started to improve but these needed to embed to show improvements can continue and be sustained to comply with regulation.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, although improvements had clearly been made since the last inspection, best interest decision making was not always recorded in the care home and we have made a recommendation about this.

Improvements had been made to the premises and furnishings since the last inspection, although this work continued to be in progress. Servicing of equipment and systems such as electrical and gas safety were completed regularly as required.

People and their relatives knew how to complain if they needed to. No complaints had been received in relation to the care home. Complaints received by people about the care agency had not always been logged or effectively monitored to ensure lessons were learnt and improvements made. We have made a recommendation about this.

People and their relatives gave positive feedback about the staff in the care home and the care agency. People felt safe with staff and felt they knew them well and provided their support in the way they wanted. The relatives of people living in the care home described their loved ones as very happy and pleased to return to their home following visits. Relatives were kept up to date with information about their loved ones, for instance, if they were unwell or had an appointment.

A person-centred approach was taken by staff in both services. Staff knew people well and supported them with dignity and respect. People were encouraged to be involved in making decisions about their care using their own communication methods when they were not able to converse verbally.

People were supported to access health care when needed to support their health and well-being. Staff helped people living in the care home to maintain a healthy and well-balanced diet. People living in their own homes were supported by care agency staff with their meal preparation if they needed this.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 10 August 2019) and there were four breaches of regulation. We took enforcement action against the provider. We served a warning notice telling the provider they must make improvements to the record keeping and quality and safety of care. We told them they must become compliant with Regulation 17 by 31 October 2019. The provider submitted a plan of action to show what they would do, and by when, to improve. At this inspection we found that although the provider and registered manager had made some improvements, they had failed to make enough improvement and they were still in breach of Regulation 17. The service remains rated requires improvement. Although improved, this service has been rated requires improvement for the last six consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, although improved, further improvement needed to be sustained and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating and to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified three breaches in relation to accurate record keeping and effective quality monitoring, the safe management of medicines and staffing levels, at this inspection.

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

Follow up

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. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Welcome Home is registered with CQC to provide two services: A residential care home and a community based domiciliary care agency which delivers personal care to people in their own homes.

The care home provides accommodation, care and support to up to five adults with a learning disability. Five people were living in the service at the time of our inspection. People had complex care needs, including learning disabilities, autism and physical health needs such as epilepsy and diabetes. People had limited verbal communication so were unable to speak directly to us.

The care agency was providing personal care to approximately 41 people at the time of our inspection. The care agency is run from an office within the grounds of the care home with a separate staffing group. The provider also provided care and support through the care agency to four people with a learning disability living in a 'supported living' setting in one property, so that they can live as independently as possible in their own home.

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

People’s experience of using this service:

Risks relating to individual people were not assessed and recorded appropriately, incorporating their personal circumstances, to make sure measures were in place to protect them from harm.

A robust process was not used when recruiting new staff to the services to make sure only suitable staff were employed to provide care and support to people who may be vulnerable.

People living in the care home were not supported by staff who had the up to date training they needed to meet people’s particular needs. Staff in the care home and the care agency did not receive practical moving and handling training to make sure they were competent to assist people with poor mobility to move safely.

The basic principles of the Mental Capacity Act 2005 had not been followed to make sure the rights of people living in the care home were upheld. DoLS authorisations had not been reviewed to make sure conditions were met. A mechanism to review authorisations was not in place to make sure new applications had been made when necessary.

The management and leadership of the services continued to need improvement to make sure people were provided with a safe and good quality service.

Peoples and relatives views had not been consistently sought to use their feedback to make improvements to the whole service. We have made a recommendation about this.

Although people living in the care home accessed the community and followed activities they enjoyed, records were not available to show if new activities had been tried, to widen people’s interests and social interaction. We have made a recommendation about this.

People were supported to access health care when needed to support their health and well-being. Staff helped people living in the care home to maintain a healthy and well-balanced diet. People living in their own homes were supported by care agency staff with their meal preparation if they needed this.

Staff across both services knew people well and supported them with dignity and respect. People were encouraged to be involved in making decisions about their care using their own communication methods when they were not able to converse verbally.

People using the care agency thought the service was managed well. Staff spoke highly of the registered manager, describing them as approachable and supportive, which helped them to do their job.

Rating at last inspection:

Requires improvement (Report published 10 May 2018). This is the fifth time this service has been rated requires improvement.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Responsive and Well Led to at least good. We found the provider had undertaken some of the actions in their action plan but had not made enough improvements to achieve the rating of Good.

Why we inspected:

This was a planned inspection based on the previous rating.

Enforcement:

Please see the ‘action we have told the provider to take’ section towards the end of this report.

Follow up:

We will continue to monitor this service and plan to inspect in line with our inspection schedule for those services rated Requires Improvement overall with one domain rated as Inadequate.

Welcome Home is registered with CQC as both an accommodation based care home and a community based domiciliary care agency (DCA) which delivers personal care to people in their own homes. The domiciliary care agency is run from an office within the grounds of the care home with a separate staffing group to the care home.

People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during the inspection of the care home. The care home provides care and support to up to five adults with a learning disability. Five people were living at the service at the time of our inspection. People had complex care needs, including learning disabilities, autism and physical health needs such as epilepsy and diabetes. People had limited verbal communication so were unable to speak directly to us.

A domiciliary care agency provides personal care to people living in their own houses and flats in the community. The Welcome Home care agency provides a service to any adults who require support. At the time of the inspection approximately 45 people were receiving personal care in their own homes. The provider also provided care and support to four people with a learning disability living in a ‘supported living’ setting, so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements within supported living. CQC does not regulate the premises used for supported living. Not everyone using Welcome Home supported living service receives regulated activity; 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.

We have reported on the services provided by the care home and the care agency separately under the evidence sections of the report. Where the evidence we found related to both services we combined the reporting. We have reported on the evidence found within the supported living service under the care agency as this is where the regulated activity ‘personal care’ is reported.

A registered manager was in post within the service. 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 our last inspection on 20, 22 and 23 June 2017 we found breaches of Regulations 11,12,17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Three breaches had continued since the previous inspection relating to, people’s basic rights and consent to care and treatment; staff support, training and supervision; management, leadership and monitoring of the service provided. One further breach was identified relating to the management of risk and safe medicines management.

We asked the provider to take action to meet Regulations 11 and 12. We took enforcement action against the provider and the registered manager and told them to meet Regulations 17 and 18 by 04 September 2017.

The provider sent us an email on 24 August 2017 telling us the action they were in the process of taking to comply with Regulations 11, 12, 17 and 18. They did not confirm a date with us when they would be meeting the regulations by.

At this inspection, we found the provider and registered manager had made some improvements to all the identified areas within the service, although further improvements were required and work was still in progress to meet the regulations.

Care home

Although some individual risk assessments were in place and these had been reviewed since the last inspection, we found that many risks identified through care planning had not been assessed to ensure guidance was in place for staff to keep people safe.

Improvements had been made to ensuring people’s rights were upheld within the basic principles of the Mental Capacity Act 2005 (MCA 2005), however these needed to be developed further. We have made a recommendation about this.

Improvements had been made to the safe administration of people’s prescribed medicines. These were now better organised and a system was in place to make regular checks to prevent errors and omissions.

The registered manager was in the process of recruiting new staff to the care home, however, there were suitable numbers of staff to provide the care and support people were assessed as requiring.

Staff knew people well and spent time with people individually, responding to their individual needs. Care plans were person centred with detailed information about each person. Improvements had been made to the recording of people’s activities and interests. The registered manager was continuing to make improvements to these.

People’s privacy and dignity were respected and they were supported to maintain and increase their independence skills. People living in the care home were relaxed and smiling, responding to staff chatting and singing.

Fire alarm testing and servicing of fire equipment and utility systems such as gas and electrical continued to be carried out at the appropriate intervals by suitably qualified technicians. Fire evacuation drills were now undertaken and recorded appropriately.

Care agency

People’s prescribed medicines were not always managed safely. Incidents had not always been investigated appropriately to ensure action was taken to avoid similar incidents happening.

Staff changes had meant the care agency management team could not always deploy staff appropriately to ensure people received the care and support they preferred and had been assessed as requiring.

Poor feedback was received from people and their relatives regarding the management of the service provided by the care agency. A consistent approach to providing a good quality service had declined due to changes in office staff.

Most people either took care of their own health care needs or a family member or friend helped them. Staff reported concerns to health care professionals or family members as appropriate. Some people required assistance with eating and drinking and preparing meals. This was clearly recorded in their care plan for staff to follow.

Feedback was sought about the service provided during the review with action taken to address concerns.

Care home and care agency

Some improvements had been made to the quality monitoring systems and checks were in place for some areas. However, the provider and registered manager had still not developed robust and consistent systems to evidence their management oversight of the service as a whole.

Although some improvements had been made to the supervision and development of staff, further improvements were necessary as staff had not received the levels of support expected and stated within the provider’s policy. Staff meetings continued to not be prioritised as a means of staff support and team building. Staff training updates had not been completed by some staff to ensure they continued to have the skills necessary to undertake their job role.

Care plans were in place describing the care and support people required following an assessment of their care needs. Care plan reviews had not always been carried out regularly and where a review had taken place, changes had not always been made to people’s care plans to reflect changes in care or circumstances. We have made a recommendation about this.

The registered manager continued to practice safe recruitment procedures to ensure people were protected from being supported by unsuitable staff.

Staff understood their responsibilities in protecting people and keeping them safe from harm. They knew who to report concerns to and who to go to outside of the organisation should they need to.

A complaints procedure was in place. No complaints had been made in the care home. Some informal complaints had been made regarding the care agency and these had been recorded and responded to individually.

Staff found the registered manager and management team were approachable and supportive.

During this inspection, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Welcome home is registered as both an accommodation based care home and a community based domiciliary care agency (DCA) which delivers personal care to people in their own homes. The domiciliary care agency is run from an office within the grounds of the care home with a separate staffing group to the care home.

The care home provided accommodation, care and support for up five adults. People had complex needs, including learning disabilities, autism and physical health needs. At the time of this inspection five people were living at the care home. The DCA service provided home care services to people within the local area. People had varying needs, some were living with dementia and needed a range of support including personal care, prompting and monitoring. Times and days of visits varied to suit individual need. At the time of the inspection approximately 40 people were receiving personal care in their own homes from Welcome Home care agency.

We have reported on the services provided by the care home and the care agency separately under the evidence sections of the report. Where the evidence we found related to both services we combined the reporting.

We last inspected the service on 06 and 07 September 2017. At that inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to Regulation 11, 12, 17, 18, 19 and 20A. Following the inspection the provider sent us an action plan to show how they intended to improve the service and meet the requirements of the regulations. The provider said they had already completed some actions and those they hadn’t completed would be completed by the end of December 2016.

At this inspection we found that the provider had made some improvements to the service, mainly in the care agency, however many further improvements were necessary.

A registered manager was employed at the service and had been in the role since the service was set up. The registered manager was registered for both the care home and the care agency. 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.

Care Home

Although individual risk assessments were in place, these had not been reviewed since 2014 or 2015 so changes in people’s circumstances had not been taken into account to ensure the risks continued to be managed effectively. Some risks had not been identified.

Some improvements had been made to the management of people’s prescribed medicines, however, there were continued concerns which posed a risk to the management of medicines.

Although a fire risk assessment was in place and fire testing and servicing of equipment carried out, practiced fire evacuation drills had not taken place to ensure the safety of people and staff in the event of a fire. We have made a recommendation about this.

Staff continued to have limited or no one to one supervision sessions with their manager or the opportunity to attend staff meetings. Most of the staff training required to gain the basic knowledge to support people well had not been updated or completed by staff.

Some mental capacity assessments had been undertaken to determine people’s mental capacity to make less complex decisions, however, these had not been reviewed and assessments to make new decisions had not been completed. Where decisions had been made, a best interests process had not been followed as determined within the Mental Capacity Act 2005.

Staff knew people well and spent time with people individually, responding to their individual needs. Care plans were person centred with detailed information about each person, however, these had not been appropriately reviewed. We have made a recommendation about this.

People’s privacy and dignity were respected and they were supported to maintain and increase their independence skills.

Although people clearly went out to some activities, there was no evidence of this through activity plans or a specific care plan. We have made a recommendation about this.

Care agency

Individual risks faced by people supported in their own homes were identified with plans in place to control the risks. Risk assessments were reviewed regularly. Environmental risks were identified at the initial assessment to ensure people and staff were kept safe from hazards inside and outside the person’s home.

Medicines were now managed well where people did require the support of staff to administer their prescribed medicines.

Care needs were assessed before support commenced. Care plans were reviewed regularly with people and their relatives to make sure they continued to be supported in the way they wanted and to suit their changing needs and circumstances. Feedback was sought about the service provided during the review with action taken to address concerns quickly.

Care home and care agency

Although positive comments were made by people, relatives and staff about the registered manager, many concerns were found about the management and leadership of the service. No clear oversight of the services provided by the provider was evidenced.

Staff understood their responsibilities in protecting people and keeping them safe from harm. They knew who to report concerns to and who to go to outside of the organisation should they need to.

Improvements had been made to the recruitment process and safe procedures were now in place, protecting people from being supported by unsuitable staff. There were enough staff employed to deliver the care and support people required.

Accidents and incidents were reported quickly by staff and investigated and responded to well.

People were supported to maintain their health and well-being by getting the appropriate advice and guidance from health care professionals. People were supported to maintain a well balanced diet and meal choices were based on their individual preferences.

Positive comments were made about the support received from staff and how pleased people and their relatives were with their support.

A complaints procedure was in place. Complaints made about the care agency had been investigated and responded to appropriately.

During this inspection, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Welcome home is registered as both an accommodation based care home and a community based domiciliary care agency (DCA) which delivers personal care to people in their own homes. The domiciliary care agency is run from an office at the care home.

The care home provides accommodation, care and support for up five adults, either male or female. People had complex needs, including mental health and physical health needs. At the time of this inspection five people were living at the home. The DCA service provides home care services to people within the local area. Some people are living with some degree of memory loss and need a range of support including care, prompting and monitoring. Visits range in number and time to suit individual need. At the time of the inspection 34 people were receiving personal care from Welcome Home. This DCA service is run from a separate office within the grounds of the care home with a separate staffing group, although on occasion staff working at the care home carried out visits to people in the community and vice versa.

We have reported on the services provided by the care home and the DCA separately under the evidence sections of the report, unless the evidence related to both services when we combined the reporting.

We last inspected the service on 12, 13 and 18 August 2015. At that inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to Regulation12, Safe care and treatment; Regulation 17, Good governance; Regulation 18, Staffing and Regulation 19, Fit and proper person’s employed. Following the inspection the provider sent us an action plan to show how they intended to improve the service and meet the requirements of the regulations. The provider said they would complete the actions in the plan by March 2016.

At this inspection we found that the provider had not taken action to address the breaches from the previous inspection and had made few improvements to the service provided. Improvements had been made to people’s care plans within the DCA service and people now had regular reviews of their care. Individual risk assessments had been improved within the DCA service.

Care Home

Risks to people’s safety and wellbeing were not managed effectively to make sure they were protected from harm. The care home did not have all associated individual risk assessments in place to identify and reduce risks that may be involved when caring for people in the home.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. Staff were trained in the Mental Capacity Act 2005 and showed they understood and promoted people’s rights through asking for people’s consent before they carried out care tasks. Where people lacked the mental capacity to make decisions the registered manager had not always been guided by the principles of the Mental Capacity Act (MCA) 2005 to ensure any decisions were made in the person’s best interests. Mental capacity assessments had not been undertaken with people living in the care home before care planning decisions had been made. There was no evidence of best interest’s decisions within the care home to make sure people’s rights were upheld.

There was plenty food and snacks available in the care home based around people’s preferences. Staff were aware of special diets people were advised to follow and factored this in when choices were made.

People living in the care home were clearly happy and relaxed within their home. Feedback from relatives was very positive about their loved one’s safety and welfare. The home had a pleasant atmosphere where people were at the centre of everything the staff did.

People living in the care home had many activities and each had their own car so they could access their interests outside of the home. People also took part in activities and interest within the home. Activity plans were not available to evidence the busy lives people led and to make sure new staff had a clear idea of people’s plans. We have made a recommendation about this.

DCA

DCA staff recorded informal, or verbal, complaints on contact sheets and dealt with these straight away. However, they were not logged as complaints and therefore not analysed in order to learn from mistakes and make improvements to service delivery. We have made a recommendation about this.

People were very positive about the care and support they received from the DCA staff. They all said they felt safe with the staff and always received the care they needed. The office staff knew people well and most of them spent some time supporting people.

Care home and DCA

The provider did not follow the appropriate guidance to make sure the recording of the administration of medicines was safe and the information required was available. However, medicines were managed well in some areas within both the care home and DCA service.

The provider did not follow safe recruitment practices. Essential documentation was not available for all staff employed in either the care home or the DCA. Gaps in employment history had not been explored to check staff suitability for their role. Appropriate references were not always requested.

Staff were not supported appropriately. Individual one to one supervision meetings and appraisals had not taken place with staff working in the care home. Some supervision meetings had taken place with staff in the DCA service although not often or regular. Staff had not had the opportunity to attend regular staff meetings to receive information, updates and support.

The provider did not have effective systems in place to enable the registered manager to assess, monitor and improve the quality and safety of the two services or identify and manage all the risks to people’s safety. Shortfalls had not been identified by the provider or registered manager and actions had not been taken in a timely manner to improve the quality of both services.

The provider asked people and their relatives for their views in both services. Feedback was mainly positive. The provider did not analyse the feedback and comments received in order to improve the quality of the services.

There was a registered manager based at the service. The care home and the DCA service had a combined 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.

There were sufficient numbers of staff in both services to deliver the care and support required. Staff enjoyed their work and said they were not rushed, always had time to chat to people and assist people with enjoyable personal activities.

People’s health needs were well looked after in both services with close communications with health and social care professionals.

People, their relatives and staff all thought the registered manager was approachable and always put people first. Staff were happy in their role and felt confident to raise concerns with any of the management team at any time.

During this inspection, we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We served a warning notice following our visit to the service on 7 January 2014 as we found that the provider did not have effective recruitment procedures in place. This meant the provider could not ensure that persons employed were of good character and suitable to care for people using the service.

At this visit, we were told that the agency employed 12 support workers. We examined four staff recruitment files for the four newest members of staff. We found that improvements had been made and there were procedures in place to ensure that staff employed by the agency were suitable. We saw that the staff recruitment files had been put together using a structured order and filed appropriately.

The staff recruitment files we saw included a completed application form, and confirmation of any previous relevant training. We saw that a full employment history had been obtained and this included information in relation to any gaps in employment. Applicants were selected for interviews, and we saw that interview records were maintained.

Successful applicants had provided proof of their identity, and their eligibility to work in the UK. Other required checks were completed, including two written references and Disclosure and Barring Service (DBS) criminal record checks. This showed that the service was taking suitable measures to employ people who were safe to work with vulnerable adults.

The improvements seen in the content of the staff recruitment files and record keeping showed the provider had a robust and effective recruitment and selection procedure in place.

Two inspectors carried out a responsive follow up review visit on the 07 January 2014, in order to see what improvements had been made and to judge whether the service was compliant with Regulation 20 and Regulation 21. We focused our inspection on the domiciliary care agency records when checking compliance with Regulation 20 and Regulation 21, as this was where we had found non-compliance at our visit on 16 October 2013. During the visit we spoke with the registered manager, the office manager and the administration person for the domiciliary care agency services.

We found the support plan records for the domiciliary care agency service contained insufficient information to enable staff to meet the needs of people and records were not always appropriately signed and dated.

Insufficient recruitment checks had been undertaken before staff began work for the domiciliary care agency service. For example, criminal record checks had not always been sent for prior to the person starting work with the agency and reasons for any gaps in employment history had not been recorded.

Staff training records were not up to date, and the manager was unable to show us evidence that all staff had been suitably trained in for example, moving and handling.

We found overall that the service was non-compliant with Regulations 20 and 21, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

We spoke with staff and management, observed staff interaction in the care home, and spoke with two people on the telephone who used the domiciliary care agency service.

We saw that there was an action plan in place following a Local Authority Quality Monitoring visit. The manager told us that she was currently addressing the actions required and that she had already implemented a written record of staff meetings that took place and had set up regular staff supervision sessions.

Support plan records for the care home service showed that the people were supported with their care in a way that was individual and in accordance with their wishes. However, the support plan records for the domiciliary care agency service contained insufficient information to enable staff to meet the needs of the person being supported.

We found that the care home service handled medicines appropriately.

Appropriate checks had been undertaken before staff began work for the care home service, however a robust recruitment procedure was not evidenced for the domiciliary care agency service.

People who received a service from the agency said 'This is the best service ever. They put themselves out to help' and 'Very pleased with the service'.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

Relatives of people that used the service had answered positively to all the questions in the quality monitoring survey. One relative had commented 'X appears well looked after, always clean and tidy. I miss X but I have never had any concerns about her wellbeing'.

We found that improvement actions made at the last inspection visit had been completed. These included the following changes. The garden area had been made safe. Medication records were appropriately completed and up to date with medication audits in place. The information currently being received from quality monitoring surveys was in the process of being collated by the manager.

The service had recently registered for the regulated activity of personal care and we saw that a small domiciliary care service was operated from an office in the grounds of the premises.