Archived: 1st Class Nursing Agency

1st Class Nursing Agency is a domiciliary care agency that supports people in the Kirkby and Ormskirk area to remain independent in the comfort of their own home with the support of care services. The agency has its main office in Burnley, but has a manager located in Kirkby, who liaises with people who use the service, and the agency staff.

At the last inspection on 02 December 2016, the service was given an overall rating of Requires Improvement. The Safe domain was rated as Inadequate. The Effective, Responsive and Well-Led domains were rated as Requires Improvement, and the Caring domain was rated as Good. At this inspection we found that the agency had met the previous breaches in the Regulations. However, we did identify areas were the agency was in breach of further Regulations, and areas were minor improvements could be made to formalise the systems in place. This would ensure that the records relating to staff competencies and good governance was as robust as they could be. The overall rating for the service is now Good.

The agency did not have a registered manager in place at the time of this inspection. This was a breach of Regulation 5 Registration Regulations 2009 (Schedule 1) Registered manager condition.

The location from which the regulated activities were being provided was not registered with the Commission at the time of the inspection. This was a breach of Section 10 Health and Social Care Act -Carrying on a regulated activity without being registered.

The legal obligations placed on the agency were understood by the service provider and manager. In June 2017, the agency closed its registered location in Ormskirk, and moved the operation of the service to its registered office in Burnley. The service provider applied to the CQC for their Ormskirk office to be removed from registration, and for their Burnley office to be added. However, the accompanying Registered Manager application was withdrawn by the applicant, and as a result, the Burnley office application was not progressed. In Dec 2017, the service provider submitted a further application to the CQC to add a location (the Burnley office), and this was accompanied by a Registered Manager application.

At the previous inspection in 2016, we found that the service did not have robust policies and procedures around the safe recruitment of staff or medicines management. We also found that the service did not have a robust quality auditing system in place. There were no audits for care files and medication administration records. These shortfalls in systems, processes and quality assurance, amounted to a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good Governance.

At this inspection, we found that although quality assurance arrangements had improved, further work was needed to bring about further improvements. Some of the quality assurance records were disorganised and held on two different computer systems, and the medicines audit tool lacked detail regarding the competency of staff. We recommended that developments are made to the governance systems and that the service provider formalise and organise their audit and recording systems.

We recommended that a formal process be introduced relating to ensure medicines are only administered by designated and appropriately trained staff who have had their competency thoroughly assessed.

At this inspection, we found that the service was now compliant with the Mental Capacity Act (MCA) code of conduct, and that consent was always sought before care was provided, and when decisions were made on behalf of or about individuals, and then this was appropriately documented. This meant that people’s rights were being protected.

We also found that people’s care, treatment and support was set out in a written plan that had been devised by the agency following their own assessment of need, and that this plan described what staff needed to do to make sure personalised care was provided.

Everyone we spoke with told us they felt safe receiving care and support and that staff were kind, caring and professional. We were informed that people felt comfortable in the presence of the care staff that assisted them.

Staff we spoke with had a good understanding of the services safeguarding policy and knew how to recognise and report potential safeguarding issues.

People were supported to take their medicines safely and processes were in place to order, store and record people’s medicines. No-one we spoke with raised issues about how their medicines were managed.

The people we spoke with were happy with the consistency, timeliness and ability of the care staff that assisted them. Staffing levels were judged to be appropriate for the assessed needs of the people using the service.

Staff received an effective induction prior to them working alone with people. Staff then went on to receive training, supervision and support to enable them to carry out their role effectively.

People told us their privacy and dignity were respected and promoted by the care staff and that staff treated them well. People were involved in decisions about their day to day life and that people’s involvement was in line with their wishes.

People and relatives we spoke with told us they knew how to raise issues or make a complaint and that communication with the service was good. Care plans were seen to be person centred and reflective of peoples care and support needs. People were given choices in how they wished their support to be carried out and with daily living tasks such as what time they got up, went to bed or received assistance.

People we spoke with told us that they felt the service was well run and managed well. There was a range of auditing and monitoring in place to ensure a good overview of the service was maintained.

The inspection of this service took place across two dates; 29 September and 5 October 2016, this was the first time the service had been inspected under the comprehensive methodology. The service was given 24 hours’ notice prior to the inspection so that we could be sure someone would be available to provide us with the information we required.

There was not a registered manager in post. The registered manager left the service in December 2015 and was de-registered by the commission 7 April 2016. The service has identified a manager who has been employed by the service for many years in another capacity. They are currently undergoing the registration process to become 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.

We looked at recruitment processes and found that the service did not have recruitment policies and procedures in place to help ensure safety in the recruitment of staff. We checked how staff had been recruited and found that this was not always robust.

We found a lack of consistency in the way people's risk had been assessed and managed. Risks to people were not always sufficiently managed to avoid harm. We looked at people’s care plans and found gaps in information regarding people’s medicine regimes. We saw no support plans to guide staff when giving medicines which could have put people at risk of medication mismanagement.

Staff we spoke with told us they were given enough time with people, were given time for travelling and that visits to people did not overlap. People we spoke to told us that staff stayed for the allocated time.

We looked at how people were protected from bullying, harassment, avoidable harm and abuse. We found that the service followed safeguarding reporting systems as outlined in its policies and procedures. We felt reassured by the level of staff understanding regarding abuse and their confidence in reporting concerns.

We looked at how the service gained people’s consent to care and treatment in line with the Mental Capacity Act 2005 (MCA). We found that the principles of the MCA were not consistently embedded in practice.

We found staff were not being supported by way of regular formal supervision and appraisals, however, staff did feel that they were supported in their role. We looked at the provider’s training matrix, which covered multiple courses including moving and handling, safeguarding, health and safety, medicines awareness and infection control. We found that the service promoted staff development and had a rolling programme to ensure that staff received training appropriate to their role and responsibilities. Staff received training to help ensure they understood how to respect people’s privacy, dignity and rights. People consistently told us that the staff were caring and understood people needs.

We found there was a clear assessment process in place, which helped to ensure staff had a good understanding of people's needs before they started to support them. We noted that the assessment process always involved a visit to the service user's home and included the views of other professionals involved in their care. However, we found people's care had not been routinely reviewed. Documentation held was not always an accurate, complete and contemporaneous record.

We viewed very detailed daily care records, which gave an overview of the care provided at each visit. In addition, the records demonstrated that support was provided in line with the service users' personal needs and wishes.

The service had a complaints procedure which was made available to people they supported and their family members.

We looked at policies and procedures relating to the running of the service. We found that the service did not have robust policies and procedures around the safe recruitment of staff or management of medicines.

We found that the service did not have a robust quality auditing system in place. There were no audits for care files and medication administration records. We found issues that could have been identified by audits.

There was a positive and sustained culture at 1st Class Nursing Agency that was open, inclusive and empowering. Staff were motivated and told us that management at 1st Class Nursing Agency were excellent. Without exception people using the service, relatives and care workers all spoke very highly of the management team.

We found the manager was familiar with people who used the service and their needs. When we discussed people's needs, the manager showed good knowledge about the people in her care.

We found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of safe care and treatment, need for consent, good governance and fit and proper persons employed. You can see what action we have taken at the end of this report.