Proline Care Limited

Proline is a domiciliary care agency that provides personal care and support to people in their own homes. At the time of our inspection there were 54 people receiving personal care.

People’s experience of using this service:

Systems to monitor the quality and safety of the service had not always been effective at identifying where the registered provider needed to make improvements. For example, care records and risk assessments did not detail how risks would be managed effectively.

People received their medicines safely and as prescribed. Staff sought people’s consent before providing care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s rights to privacy and their dignity was maintained and respected by the staff who supported them. People were supported to express their views about their care. The views of people on the quality of the service was gathered and used to support service development.

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 November 2018). The service remains rated requires improvement. This service has been rated requires improvement (one of which was rated inadequate) for the last four consecutive inspections.

Why we inspected

This was a planned comprehensive inspection.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Not everyone using Proline Care Limited 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 our last inspection in February 2018 we identified improvements were needed under the key questions of ‘Is the service safe, effective and well-led. We identified two breaches of the Health and Social Care Act 2008. We found under the key question is the service 'safe' that the registered provider was not ensuring the safe care and treatment of people through appropriate management of medicines and this was a continued breach of Regulation 12 safe care and treatment. Under the key question is the service 'effective' we found the registered provider had not consistently applied their responsibilities under the Mental Capacity Act (2005). Under the key question is the service 'well led' we found the systems and processes to monitor the safety and quality of care people received was not effective and this was a continued breach of Regulation 17 Good governance. Following our inspection, we issued a warning notice in relation to Good Governance. A warning notice is one of our enforcement powers.

This inspection took place on 24 September 2018 to follow up on our previous findings. We returned on this occasion to check whether people were safe and that the provider was taking the necessary action to improve the quality of care and reducing the risks to people. During this inspection the service demonstrated to us that some improvements have been made, further improvements were required and the service was now meeting the regulations.

There was a registered manager in post 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.

People's risk assessments did not consistently cover all potential areas of risk, such as skin integrity, choking and nutrition and did not consistently mitigate risks. People felt safe in the care of staff members and were happy with staffing levels. The provider had appropriate systems in place to support staff to raise any safeguarding concerns, and the provider was open in learning lessons from incidents and improving the service. People told us they were happy with the management of their medicines. Staff had access to appropriate personal protective equipment (PPE) to help prevent the spread of infection.

People told us they received effective support. Systems were in place to ensure that staff received appropriate supervision to support them in their roles. Staff felt they were trained to the right level to effectively work with people. Checks were made on the ongoing competency of staff and staff felt they could ask for extra training and support at any time. People told us that staff sought their consent prior to carrying out care and made people aware of the actions they were to take.

People were supported to eat meals of their choosing and were supported to access health professionals when necessary.

People told us care staff were very caring, kind and compassionate. Staff enabled people to be independent and to make choices where possible. People's privacy and dignity needs were maintained by staff members caring for them.

People told us they were provided with a responsive service. People received care and support which was assessed, planned and delivered to meet their individual needs. People and families spoke about being involved in the process of writing and reviewing their care plans. People knew how to make complaints and felt confident they would be addressed.

The providers systems and processes in place to monitor and audit the service required improvement. We recognised the improvements made following our last inspection and the service demonstrated how they promoted a more person focused approach. Although we found that records management had improved further improvements where still needed regarding prescribed topical creams, risk assessments and quality monitoring of the service.

Not everyone using Proline Care Limited 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 announced comprehensive inspection in August 2017, we judged that improvements were required in delivering a safe, effective and well-led service. During our August 2017 inspection we found the provider continued to be in breach of the regulation related to the management of medicines and good governance. This was because the registered provider had failed to establish and operate effective systems to ensure they were meeting the regulations, or to monitor the quality and safety of the service. In addition we found partial improvements had been made to meet the warning notice issued 10 May 2017 in relation to Good Governance. A warning notice is one of our enforcement powers. 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 question ‘is the service safe, effective and well-led’ to at least good.

We undertook an announced focused inspection of Proline Care Limited on 06 February 2018. This inspection was carried out to check whether improvements to meet legal requirements planned by the provider after our inspection in August 2017 had been made. The team inspected the service against one of the five questions we ask about services: Is the service well led? This was because the service was not meeting legal requirements at our last inspection. This report only covers our findings in relation to this focussed inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Proline Care Limited on our website at www.cqc.org.uk.

During this focused inspection in February 2018 we found improvements were still required in governance and leadership. We identified that some action had commenced or been taken, but that this had not been sufficient, effective or timely enough to drive forward all of the improvements required. We found improvements had been made to meet the Warning Notice of Regulation 17 that we served in May 2017. Further improvements were needed and we are considering what further action to take. The service continues to be rated as 'requires improvement', because, although some action had been taken, other actions had been planned, but not yet fully implemented.

There was a registered manager in post who was present throughout 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.

Regular audits and quality assurance checks required further development in order for the service to improve. People who used the service described how their experiences of the service had improved. Staff told us there had been improvements in how the service was managed.

At this inspection of August 2017 whilst we found improvements had been made the service continued to remain in breach of regulation 17. Good governance. We will continue to monitor the service to ensure the improvements have been sustained and review this at our next inspection.

At our last comprehensive inspection in March 2017 the overall rating for this service was ‘Requires improvement’. However, the service remained 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. Special Measures is a process whereby we expect the provider to seek out appropriate support to improve the service. We found that the registered provider had addressed some of the concerns that we had identified at our last inspection. However there were areas of further improvement required in respect of staffing levels, management of medicines and governance of the service. After our inspection in March 2017 we served a Warning Notice to the registered provider which required them to be compliant with this regulation by 14 August 2017. A Warning Notice is one of our enforcement powers. We asked the registered provider to send us an action plan to show how they would meet the legal requirements of the regulations.

We undertook this announced inspection on 30 August 2017 to check that the registered provider had followed their own action plan and to monitor their compliance with the legal requirements of the regulations. During this inspection we found some improvements, and effective plans to improve were in place to remove the service from 'special measures'. However, at this inspection, we found partial improvements had been made to meet the warning notice of Regulation 17. Further improvements were needed and we are considering what further action to take. The service continues to be rated as 'requires improvement', because, although some action had been taken, other actions had been planned, but not yet fully implemented.

There was a registered manager in post who was present throughout 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.

Medicines were not consistently administered to ensure people’s safely. People were not consistently protected from the risk of unsafe practice because risks assessments were inconsistent and staff did not consistently have sufficient guidance on how to support people safely. People told us that they felt safe with the staff who provided their care and support and that the staffing levels had improved following our last inspection.

People told us that staff sought their permission before providing care and support. However, we identified that the registered provider had not consistently understood their obligations under the Mental Capacity Act 2005. Staff had been provided with induction training and received training to update their knowledge and skills. People were supported by staff to prepare and cook meals when necessary. People were supported to access healthcare services as required.

People told us they were cared for by kind and thoughtful staff who knew their individual preferences and their likes and dislikes. Care was planned with the involvement of people who used the service. Staff maintained people’s privacy and dignity whilst supporting them to remain as independent as possible.

Person-centred care plans had been developed to enable staff to provide care the way that people preferred. Staff spoke compassionately about the relationships they had developed with people they were supporting. There was an improved system in place to record and investigate complaints. People told us they were confident that concerns raised would now be addressed in a timely manner.

The quality assurance systems in place were not consistently effective and had not identified the shortfalls we had highlighted at our previous inspections. At this inspection, we found partial improvements had been made to meet the warning notice of Regulation 17. People and their relatives were encouraged to share their opinions about the quality of the service. Most staff spoke enthusiastically about the improvements already made in the quality of the service.

You can see what action we told the provider to take at the back of the full version of this report.

At our last comprehensive inspection in October 2016 we found that the care and support people received from the service was inadequate. This was because people were not kept safe from the risk of actual and potential harm. Known risks to people were not properly assessed, reviewed or managed. There were insufficient numbers of staff available to meet the needs of people and people often experienced late or missed calls. The management of medicines was not safe which meant there was a risk that people did not get their medicines as prescribed. We also found that the registered provider had not ensured that all people who used the service were treated with dignity and respect and was not ensuring the care and treatment provided was with the consent of the relevant person. In addition the registered provider did not have robust systems in place to monitor the quality of the service and did not ensure that all complaints were investigated and responded to. Following the inspection we met with the registered provider who submitted an action plan detailing how they would improve to ensure they met the needs of the people they were supporting and the legal requirements.

We undertook this announced inspection on 14 and 15 March 2017 to check that the provider had followed their own plans to meet the breaches of regulations and legal requirements. We found that the registered provider had addressed some of the concerns that we had identified at our last inspection. However there were areas of further improvement required in respect of staffing levels, management of medicines and governance of the service.

There was a registered manager in post who was present throughout 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.

Our inspection identified that whilst some changes and improvements had occurred within the service outstanding issues continued to place people at risk of receiving a consistent safe service at all times. Some people told us that the service had improved in some areas. Others told us it was not good in that there was a lack of staff and that people did not always know which staff member was to provide their care and at what time during weekends.

People told us that they felt safe with the staff who provided their care and support. People were not always protected from the risk of unsafe practice because risks associated with their health conditions had not consistently been assessed and staff did not have sufficient guidance on how to support people safely. There were insufficient staff numbers consistently available to meet people’s needs in a timely manner. Some aspects of the management of medicines had improved but we could not consistently determine from some records that people received their medicines as prescribed.

People told us that on day to day matters staff sought their consent before caring for them.

Records showed that consideration was given to people’s needs under the MCA in care planning. We were unable to determine if staff had got the appropriate up to date knowledge and skills. People told us that they enjoyed their food and had a choice of food to ensure a healthy diet. People were supported to maintain their health.

People told us that they were supported by staff who were compassionate and caring. Staff we spoke with demonstrated a positive regard for the people they were supporting. Some decisions people had made about how they wanted their care provided had not been respected.

People told us that the service were not consistently responsive to their needs but told us that staff worked flexibly to support them. Care was planned with people’s involvement but we found care plans were not always up to date with people’s changing needs. There was an improved system in place to identify, record and report on complaints. However whilst people told us they knew who to complain to, they told us they were not confident that their concerns would be responded to appropriately.

Some people told us that were not happy with the way the service was managed in respect of weekend calls and communication from the management team. People had been encouraged to share their experiences of the service. Staff told us that they lacked confidence in the office management team. We found that whilst there were some systems in place to monitor and improve the quality of the service provided, but these were not always effective in ensuring the service was consistently well led and compliant with the regulations.

You can see what action we told the provider to take at the back of the full version of this report.

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.

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.

There was a registered manager in post who was present throughout 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 last comprehensive inspection this service was placed in special measures by CQC. At the inspection of this service on 4 and 18 October 2016, breaches of six regulations were found in which two of these were in relation to the key question, ‘Is the service safe?.’ This was because there were insufficient numbers of staff available to meet the needs of people and people often experienced late or missed calls. The management of medicines was not safe which meant there was a risk that people did not get their medicines as prescribed. The overall rating for this service was ‘Inadequate’.

This inspection found that whilst there had been improvements in the key area we looked at: ‘Is this service safe?’ there was not enough improvement to take the provider out of special measures. Another inspection will be conducted within 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.

This report only covers our findings in relation to the key question, ‘Safe’. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Proline Care Limited on our website at www.cqc.org.uk.

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.

At this inspection people told us that they received their medicines as prescribed. However, there continued to be no consistent approach to providing guidance for staff in respect of the administration of ‘as required’ medicines. Whilst staff knew about individual risks to peoples’ health and well-being and how these were to be managed, we found peoples’ care records and supporting documents did not consistently contain sufficient guidance for staff to follow.

People and their relatives told us there had been improvements in the numbers of staff to meet people’s individual needs. People told us that they felt safe using the service and that since our last inspection they now received care and support from usually consistent and reliable staff members.

At the last inspection of this service on 2 February 2016 we identified that improvements were needed to address breaches of legal requirements. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. At that time systems and processes were not in place to effectively assess, monitor and mitigate risks relating to the health, safety and welfare of people who used the services. The provider had not ensured the proper and safe management of medicines and there were ineffective quality assurance systems in place for the effective running of the service.

We undertook this announced inspection on 4 and 18 October 2016 to check that the provider had followed their own plans to meet the breaches of regulations and legal requirements.

There was a registered manager in post who was present throughout 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.

People were not kept safe from the risk of actual and potential harm. Known risks to people were not properly assessed, reviewed or managed. There was insufficient numbers of staff available to meet the needs of people and people often experienced late or missed calls. The management of medicines was not safe which meant there was a risk that people did not get their medicines as prescribed.

People could not be certain their rights would be upheld as staff lacked knowledge. Not all staff demonstrated an understanding of the mental capacity act and what it meant for the people who used the service.

People told us that they were supported to access healthcare professionals. However recommendations made by professionals about support needed were not always followed or were not always included in the care plans to guide staff on how people were to be supported.

People’s dignity and privacy was not always respected. People told us that they made decisions about how they wanted their care provided but this was not always provided as requested. Most people told us that generally they received care and support by kind and caring staff.

People told us that they had been involved in the formulating of their care plans. However, records did not always contain accurate and up-to-date information. People and their relatives told us they felt confident to raise concerns but most people told us that their concerns were not responded to and changes were not made. There were no effective systems in place to ensure complaints were responded to in an appropriate and timely manner.

Some people were not happy with the way the service was managed. Feedback that had been sought from people had not been utilised to drive continual improvement. Staff told us that they did not receive on-going supervision in their role. We found that whilst there were some systems in place to monitor and improve the quality of the service provided, these were not always effective in ensuring the service was consistently well led and compliant with the regulations.

You can see what action we told the provider to take at the back of the full version of this report.

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 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.

People and their relatives were very complimentary about care staff and the standards of care being provided. Comments included, 'The staff are very friendly and good at their jobs' and I'm quite happy with my carers, they are respectful and very kind.'

We examined care plans and found that people's needs were properly assessed and that care and support was planned and delivered in line with their individual care plans. We found that people who used the service had given their consent and were consulted about the care and support they received.

People's privacy, dignity and independence were respected and their views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Care staff were suitably trained, supervised and supported to deliver care safely and to an appropriate standard.

We found that the provider had an effective system to regularly assess and monitor the quality of service that people received and regularly sought their views and feedback.

We concluded that Proline Care Limited provided a safe, reliable and effective service.

Our inspection confirmed much of the feedback we had received. We found that care and treatment was planned and delivered in a way that ensured people's safety and welfare.

People told us, 'I can't speak more highly of them, they are really wonderful' and 'I feel safe with them.'

Our conversations with people using the service confirmed that carers were respectful, caring and professional and that the care co-ordinator was approachable and responsive to suggestions and feedback. It was clear that staff had a good knowledge of the people they cared for and were familiar with their preferences and health conditions.

People's care records showed that Proline completed a detailed assessment of their needs before a service was provided to them.

We found that people were safe and their health and welfare needs were being met because care staff had appropriate skills and experience. We also found that people who use the service were protected from the risk of abuse.

Relatives of people using the service also made complimentary comments about the staff at Proline. We were told. 'We are really happy with them' and 'They are well trained.'