Archived: Direct Health (Stockton on Tees)

Direct Health is a domiciliary care agency which is registered to provide personal care to people in their own homes. At the time of our inspection the service was providing personal care to 348 people.

There was a registered manager in post who became registered with the Care Quality Commission in March 2017. 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 the systems in place for medicines management and found they did not always keep people safe. There was not an effective system to check to see if medicines records at the office reflected current medicines people were being supported with. Records written by staff did not provide the correct or enough information to support safe administration.

Risk assessments were in place; however they did not always provide detailed information for staff to mitigate the risk. Where new risks had been identified through a review a new risk assessment was not always in place.

Records needed to be more consistent and contain more detail. We have made a recommendation about this. Although the provider and registered manager completed audits, they had not highlighted all the concerns we raised.

People were supported to receive care from the agency following an assessment. This covered all aspects of the care required by the person. Such as how many calls they would need each day, what their needs were in relation to mobility, continence and personal care, moving and handling and nutrition.

Staff took action to minimise the risks of avoidable harm to people from abuse and understood the safeguarding process.

Recruitment checks were in place and demonstrated that people employed had satisfactory skills and knowledge needed to care for people. All staff files contained appropriate checks, such as two references and a Disclosure and Barring Service (DBS) check.

Staff recruitment was continuously on-going to make sure the service had enough staff in the event of holidays and sickness or staff leaving.

People were supported to have maximum choice and control of their lives and staff understood the importance of consent and best practice in decision making related to the Mental Capacity Act (2005).

People were generally complimentary about staff and told us that they were treated with kindness and consideration. They had good relationships with their allocated care staff.

Staff received effective training in safety systems, processes and practices such as moving and handling, food hygiene and infection control. Staff had received supervision and a yearly appraisal that helped them to perform their duties and supported their development.

Processes were in place to protect people and staff in regards discrimination and equality. People told us they were able to make choices and take control in regards their care and support and who entered their home. People confirmed they were encouraged to remain as independent as possible. Care workers had built up positive and caring relationships with people they were supporting.

People said they would be comfortable to make a complaint and were confident action would be taken to address their concerns. The provider treated complaints as an opportunity to learn and improve.

Staff told us they felt supported by the registered manager and the registered manager kept people informed of events and news relating to the agency via a newsletter.

This is the first time the service has been rated Requires Improvement.

We identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Risk assessments were not always in place and more detail was needed and medicines management was not always safe. You can see what action we told the registered provider to take at the back of the full version of the report.

In September 2015 we completed an inspection and found that the provider was continuing to fail to ensure people received safe care and treatment; to operate and establish effective systems or processes and to assess, monitor and improve the quality and safety of services provided and to ensure that staff receive appropriate training as is necessary to enable them to fulfil the requirements of their role. We issued a formal warning telling the registered provider that by 1 February and 1 March 2016 they must rectify these breaches of regulation.

At our next inspection in March 2016 and April 2016 we found that the registered provider had not rectified the breaches of condition and identified more breaches of regulation so we rated the service as inadequate. The service was placed in special measures. We took enforcement action to impose registration conditions, which required the registered provider not to take on or extend any care packages without our agreement and to supply each week information about the management of the care packages and how they dealt with missed calls.

The breaches of regulations we identified were:

• Continued breach of Regulation 12: we found the registered provider was failing to provide safe care and treatment. The staff management of medicines was not safe, risk assessments provided limited or no guidance about the ways to meet people’s needs and minimise the risks. Accidents and incidents were not recorded and acted upon.

• Continued breached of Regulation 18: We found the registered provider was not employing enough staff to cover calls safely and consistently, there was a high turnover of staff and extra calls were added onto to a care workers rota without their knowledge. Staff supervision and appraisals were not taking place and training was not up to date.

• Continued breached of Regulation 17: We found the registered provider had no system to accurately monitor care calls, rotas were not completed, there was no effective system for maintaining an accurate list of people who used the service and the monitoring the quality of the services performance was wholly inadequate.

• Breached of Regulation 11.We found the registered provider’s capacity assessments were confusing and contained typographical errors.

• Breached Regulation 9: the registered provider failed to do everything reasonably practicable to ensure people received person centred care which reflected their needs and personal preference.

• Breached Regulation 16: We found their complaints process to be confusing, there was no clear record as to whether the registered provider had acted on a complaint or an outcome to the complaint.

We inspected on the 27 September and 3 October 2016 to review the action the registered provider had taken in response to our concerns and to ensure they were compliant with the regulations. During that inspection we found improvements were still needed to be made. These improvements were related to medicines management; care files needed more person centred information and to contain information not relevant to staff for example how to clean a Percutaneous endoscopic gastrostomy (PEG) when this was not the staff members responsibility; and monitoring and assurance tools had been allocated but were yet to be implemented.

Direct Health (Stockton) provides personal care for people in their own homes in Stockton, Eaglescliffe and Yarm. It is a large service and at the time our inspection in February 2017 it was providing care to approximately 400 people and employing approximately 200 staff. Direct Health was providing a personal care service to 310 people in their own homes.

Following the last inspection in September and October 2016 we reviewed the conditions imposed on the registered provider’s registration and as improvement was seen we removed the condition requiring that no new packages or increased packages were accepted without our permission. Since then we found the registered provider had only accepted or extended packages when they could do this safely.

The service has not had a registered manager for over two years and this is a breach of their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection the service had a new manager who started in November 2016. This manager had started the process to register with the CQC.

During this inspection we found

Systems were in place for the management of medicines so that people received their medicines safely. However, records for the application of creams for one person were incomplete and details of the strengths and dosages of some medicines were not accurately recorded.

Care files we looked at were person centred and contained information that reflected people’s current and changing needs. We found the repetition of people’s needs had been reduced and care staff’s responsibilities were much clearer. The care records no longer discussed tasks the staff were not contracted to undertake.

We found improvements had been made around risk assessments and they were more person specific.

The manager and staff had an understanding of the Mental Capacity Act 2005 and had received training in this area to meet people’s care needs. The service was now using an updated capacity assessment form. Only people who they thought lacked capacity were now being assessed and best interest decisions were appropriately completed around aspects of care the registered provider needed to deliver. We saw evidence of consent.

Quality assurance audits were now taking place, missed and late calls were being monitored and audits of each person’s record book was taking place monthly. The manager had a good system in place to control the collection of people’s record books. Any concerns from these audits and staff would be asked to attend training workshops.

The manager had recently sent a survey out to gain feedback from people and their relatives. The response was positive.

Staff had a good understanding of safeguarding processes and followed these in practice. All staff we spoke with felt confident to raise any concerns they had in order to keep people safe. The service monitored accidents and incidents. Staff we spoke with said they had access to plenty of personal protective equipment (PPE).

There was enough staff and there was sufficient capacity to deliver people's care. Management of staff rotas took place and unallocated calls had reduced significantly from approximately 78% to 2%.

Training was well organised and staff were knowledgeable about the needs of the people they worked with to support them as individuals. We saw that training was up to date.

Supervisions and appraisals were taking place regularly as well as spot checks. Staff we spoke with found the supervisions to be useful.

The majority of staff felt they were supported by management. Some staff said they did not know the new manager as yet.

We found there was more consistency with people being supported by the same staff. Staff confirmed they mainly had the same clients.

We looked at the complaints file and found that complaints were documented with a full outcome. The complaints had reduced substantially since August 2016.

Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers and we saw evidence that a Disclosure and Barring Service (DBS) check had been completed before they started work at the service. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with children and vulnerable adults. To help employers make safer recruiting decisions and also to minimise the risk of unsuitable people working with children and vulnerable adults.

Staff we spoke with felt the culture of the service was now open and honest, less pressurised and the service had strengthened their values so now were providing the best care possible for people.

In September 2015 we completed an inspection and found that the provider was continuing to fail to ensure people received safe care and treatment; to operate and establish effective systems or processes and to assess, monitor and improve the quality and safety of services provided and to ensure that staff receive appropriate training as is necessary to enable them to fulfil the requirements of their role. We issued a formal warning telling the registered provider that by 1 February and 1 March 2016 they must rectify these breaches of regulation.

At our least inspection in March 2016 and April 2016 we found that the registered provider had not rectified the breaches of condition and identified more breaches of regulation so we rated the service as inadequate. The service was placed in special measures. We took enforcement action to impose registration conditions, which required the registered provider not to take on or extend any care packages without our agreement and to supply each week information about the management of the care packages and how they dealt with missed calls.

The breaches of regulations we identified were:

• Continued breach of Regulation 12: we found the registered provider was failing to provide safe care and treatment. The staff management of medicines was not safe, risk assessments provided limited or no guidance about the ways to meet people’s needs and minimise the risks. Accidents and incidents were not recorded and acted upon.

• Continued breached of Regulation 18: We found the registered provider was not employing enough staff to cover calls safely and consistently, there was a high turnover of staff and extra calls were added onto to a care workers rota without their knowledge. Staff supervision and appraisals were not taking place and training was not up to date.

• Continued breached of Regulation 17: We found the registered provider had no system to accurately monitor care calls, rotas were not completed, there was no effective system for maintaining an accurate list of people who used the service and the monitoring the quality of the services performance was wholly inadequate.

• Breached of Regulation 11.We found the registered provider’s capacity assessments were confusing and contained typographical errors.

• Breached Regulation 9: the registered provider failed to do everything reasonably practicable to ensure people received person centred care which reflected their needs and personal preference.

• Breached Regulation 16: We found their complaints process to be confusing, there was no clear record as to whether the registered provider had acted on a complaint or an outcome to the complaint.

We completed this inspection to review the action the registered provider had taken in response to our concerns and to ensure they were compliant with the regulations.

Direct Health (Stockton) provides personal care for people in their own homes in Stockton, Eaglescliffe and Yarm. It is a large service and at the time of this inspection was providing care to approximately 400 people and employing approximately 200 staff. Direct Health was providing a personal care service to 310 people in their own homes. This was a reduction from the previous inspection, as the provider had made the decision to cease to provide a service in one area of Stockton. Following the last inspection the registered provider had not accepted any new packages or increased packages unless they could provide CQC with evidence that they could do this safely.

The service has not had a registered manager for over two years and this is a breach of their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection the service had a new manager who expressed their intention to register with the CQC. The new manager had started the week before the inspection and prior to completing this report left the organisation.

During this inspection we found

We found that improvements still needed to be made within regard to medicines management. Clear and accurate records were not being kept of medicines administered by care workers. Gaps in the medicines administration records meant we could not be sure people were always given their prescribed medicines. Details of the strengths and dosages of some medicines were not recorded correctly. Care plans and risk assessments did not support the safe handling of people’s medicines. The medication policy continued to inaccurately reflect the actions staff were to take. This had been raised as a problem at the last four inspections. On the day of the inspection the registered provider ensured this document was amended.

Care files we looked at had limited person centred information and due to the lack of continuity of care not many people were receiving a personal service. We found the information confusing and struggled to determine what care was being provided. We visited one person to determine what support they received. We found that the staff understood the needs of the person and knew the extent of their role.

We found that staff did not monitor food intake, assess the impact a restricted diet might have on an individual or take any action to establish why individuals might only have a sandwich at every meal provided by the service. We spoke with one person about this and found they asked for a sandwich at every meal and found that this was because staff did not have the time to cook a meal and they disliked microwave meals. We discussed this with the area manager who following our visit ensured the care package was increased so a cooked meal could be provided.

We found that care records detailed actions staff were to complete in relation to delivering clinical actions such as dealing with catheter care and the emergency procedures if someone experience an allergic reaction. Staff were not completing these tasks. We pointed this out to the area manager and found on the second day of our visit all irrelevant material had been removed.

We found some improvements had been made around risk assessments although work still needed to be done.

The area manager and staff had an understanding of the Mental Capacity Act 2005 and had received training in this area to meet people’s care needs. The service was still using the capacity assessment form seen at the last inspection. On three separate inspections we had pointed out that this form was confusing and made it difficult to understand whether the person had capacity or not. We were shown a new form that was to be introduced after inspection. This had led to staff incorrectly completing mental capacity assessments and failing to accurately determine when someone lacked capacity to make decision. The registered provider showed us the new tool they had developed, which was clearer and would accurately outline the requirements of the mental capacity assessment. But this had not yet been introduced.

Quality assurance audits were now taking place, missed and late calls were being monitored and audits of each person’s record book was taking place monthly. Any concerns and staff would be asked to attend retraining workshops. However audits had not picked up on the concerns around medicines and missing risk assessments.

We found that accidents and incidents were now being monitored with an overall outcome.

We found the service now had enough staff and there was sufficient capacity to deliver people's care. Management of staff rotas was now taking place and unallocated calls had reduced significantly.

We saw the services training chart and a selection of certificates. We saw that training was up to date We also saw up to date certificates on staff files to evidence their participation in the care certificate and completion of specialist training courses in areas such as Diabetes, Parkinson’s care, Huntington’s Disease and Dementia. However the information held centrally did not reflect that staff had completed condition specific training such as how to use a Percutaneous endoscopic gastrostomy (PEG) to feed safely. The record suggested that staff providing this intervention had not been trained or checked to ensure they were competent. We visited one person’s home who need support with PEG feeding and found staff had received recent training, been competency assessed by district nurses. We saw that the staff who attended the person’s call were confident and competent when giving PEG feeds.

Supervisions and appraisals were starting to take place, however at the time of inspection they were still inconsistent. The supervision policy was not in line with the local authority’s contract.

Staff said they felt supported by the area manager. Staff had only just been introduced to the new manager.

Staff knew the people they were supporting regularly well, however where they were covering other people’s calls they did not know enough about these people to be assured that all of their needs were met. Care plans and phone records provided limited information.

We looked at the complaints file and found that complaints were now documented with an outcome stating whether the complainant was satisfied or not.

Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers and we saw evidence that a Disclosure and Barring Service (DBS) check h

Direct Health (Stockton) provides personal care for people in their own homes in Stockton, Billingham, Eaglescliffe and Yarm. It is a large service, providing care to approximately 700 people and employing approximately 200 staff at the time of this inspection.

The service had appointed a manager in January 2015, who at the time of inspection had applied to become registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'. The service 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. Improvements were needed in many areas where the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In September 2015 we completed an inspection and issued a formal warning telling the registered provider that by 1 February and 1 March 2016 they must improve the following areas.

• Regulation 12: People did not receive safe care and treatment due to the registered provider failing to effectively assess and mitigate the risks to service users.

• Regulation 17: The registered provider was failing to operate and establish effective systems or processes and to assess, monitor and improve the quality and safety of services provided and mitigate risks relating to the health, safety and welfare of service users.

• Regulation 18: The registered provider was failing to ensure that staff receive appropriate training as is necessary to enable them to fulfil the requirements of their role.

We reviewed the action the registered provider had taken to address the above breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also checked what action had been taken to rectify the breaches we also identified of regulation 9 (Person-centred care) and regulation 16 (Receiving and acting on complaints) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following our last inspection The registered provider sent us an action plan stating they would be compliant by 1 March 2016.

During this inspection we found

No improvements had been made to the medicine management systems since the last inspection in fact the administration of medication was worse. For example we found that the registered provider failed to ensure staff obtained information about changes to people’s warfarin medication and at times the staff we administering the wrong doses. We found that the service was failing to provide safe care and treatment by the proper and safe management of medicines.

Clear and accurate records were not being kept of medicines administered by care workers. Gaps in the medicines administration records meant we could not be sure people were always given their prescribed medicines. Details of the strengths and dosages of some medicines were not recorded. Care plans and risk assessments did not support the safe handling of people’s medicines.

Although some risks were identified at initial assessment both from the local authority and Direct Health, care records gave staff limited or no guidance about the ways to meet people's needs and minimise risks.

The service had one quality monitoring audit which had taken place in February 2016. Areas needing action from this audit had to be completed by March 31 2016. However we found that the staff had not completed all of the actions. No further audits took place, which meant that the registered provider had not checked that the actions were either completed or effective.

There were no processes for recording accidents and incidents for people who used the service.

We found that the information the management team gave us about who the people the service supported was incorrect and we phoned people who no longer used Direct Health provision.

We found the service did not have enough staff and there was insufficient capacity to consistently deliver people's care. Many staff had left employment and there were pressures on care workers to work extra hours. People who used the service did not always receive a rota and when they did the rota contained a number of unallocated calls or where a named carer was listed another carer would turn up. Management of the staff rotas was not effective and the management information around times staff called differed from the actual time the staff went to the person’s home. The managers could not provide information to show when staff could not come to work evidence that other staff had covered their work.

We saw the services training chart and a selection of certificates. The services training policy stated that moving and handling, safeguarding and medication training was to be refreshed yearly. Over 30 percent of staff had not received this refresher training.

Staff did not receive regular supervisions and a yearly appraisal. The services supervision policy did not reflect the local authority contract. We could not confirm that the service performed regular spot checks on staff, to make sure they were working within safe practices.

Staff said they did not feel supported by the manager.

Staff knew the people they were supporting regularly well, however where they were covering other people’s calls they did not know enough about these people to be assured that all of their needs were met. Care plans and phone records provided limited information.

Care files we looked at had limited person centred information and due to the lack of continuity of care not many people were receiving a personal service.

The area manager and staff had an understanding of the Mental Capacity Act 2005 and had received training in this area to meet people’s care needs. Care staff had also received awareness training in the Mental Capacity Act. We found the mental capacity form within the care plan to have typographical errors which could cause confusion. We found that staff incorrectly completed mental capacity assessments and failed to accurately determine when someone lacked capacity to make decision. We saw that staff did not complete best interest in line with the requirements of the Mental Capacity Act 2005. Thus they did not involve external healthcare professionals in the decision making process and were making best interest decisions for people who had capacity. For example staff routinely hid people’s medication and only shared the storage place via text with each other. Staff told us this occurred for everyone but could not explain why or if people had given permission for this to happen.

We looked at the complaints and compliments file, eight of the 47 complaints listed had been closed. Several complaints were awaiting outcomes and there was no indication whether those that had been closed were resolved to the satisfaction of the complainant.

Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers and we saw evidence that a Disclosure and Barring Service (DBS) check had been completed before they started work at the service. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with children and vulnerable adults. To help employers make safer recruiting decisions and also to minimise the risk of unsuitable people working with children and vulnerable adults. We found employment gaps in one person’s record and we made the area manager aware of this.

The registered provider had policies and procedures in place which were there to protect people from abuse. Staff we spoke with understood the types of abuse and what the procedure was to report any such incidents. Records showed staff had received training in how to safeguard adults. A whistleblowing policy [where staff could raise concerns about the service, staff practices or registered provider] was also in place. Staff we spoke with demonstrated what process to follow when raising concerns.

Staff we spoke with said they had access to plenty of personal protective equipment (PPE).

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

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

During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led? The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

People who used the service and their relatives had mixed views about the availability and quality of staff providing their care. People who received regular staff were reasonably satisfied with the care provided. But, many people felt they did not receive enough consistency of staff, with lots of different staff visiting, some who were unfamiliar with people's care needs. People told us that staff were often late or early, but not usually by long periods. Comments made by people who used the service included 'Generally I had the same staff, but quite a lot of different staff as well. I had to show them (what to do) every time' and 'It is not too bad in the week, but weekends are horrendous.'

We made a compliance action at our previous inspection, telling the provider to make improvements to the way medication was managed. The provider had sent us an action plan telling us about the improvements they were making and saying they would achieve compliance by August 2014. People who received help with their medication gave mixed feedback about the support they received. Comments made to us included 'They help me with all my medication......There have been no accidents with my tablets and I get them at the right time' and 'They will have mix ups with the medication even with the blister packs if I'm not checking up. This sort of mistake has happened more than once.' We found that there were still issues with the quality of recording on medication records and the information available in people's care records relating to medication. The records made it difficult to know if some people's medication had been administered safely.

Is the service effective?

People told us that their regular staff were generally well trained and competent. However, people were more critical of new and unfamiliar staff, saying that they varied in quality and attitude. For example, people said that they had experienced staff who were not caring enough, not experienced or trained enough, or did not know enough about the person they were assisting. Comments made by people who used the service included 'The regulars are good, but the new or relief staff are not so good at all' and 'Some are good, some are useless.'

Staff told us that they were not routinely provided with in-depth verbal or written information on new calls before they visited. They were provided with basic information about people's needs or changes via their mobile phones, with it being left up to individual staff to seek more information from care coordinators or care records if they felt the need.

Is the service caring?

The majority of people we spoke with told us that staff were polite and respectful, and were not unpleasant or rude. People were very complimentary about their regular staff, who they said knew them well and provided the care they needed. However, many people told us that they had experienced inconsistency in the quality of their care. For example, people told us about problems they had experienced with too many new or relief staff, who did not know their needs or were not sufficiently conscientious about their work. Comments made to us included 'There's no consistency in how different staff do the job' and 'The better staff are very caring, and I always feel safe and at ease with them and they are reliable and on time. Some are a bit like they are just doing a job and they are a bit lazy.'

Is the service responsive?

We made a compliance action at our previous inspection, telling the provider to make improvements to the records they kept. The provider had sent us an action plan telling us about the improvements they were making and saying they would achieve compliance by July 2014. We found that care records contained basic information about people's preferences and care needs. This included assessments, risk assessments and visit plans and descriptions relating to people's care needs. However, some of the care records lacked detail, were not up to date or did not provide information that was important to the person's wellbeing and delivery of safe care. We also found examples of conflicting and confusing information in people's care records.

The service had a complaints procedure and mechanisms for gaining feedback from people who used the service. Many people did not feel that the service had been able to put things right or sustain improvements when they had raised concerns about their care. Comments made to us by people who used the service included 'I have complained about the times. It gets better and drifts back again', 'Any improvements we ask for do not last' and 'I was in tears last week and could have thrown the care book at them. My complaints are not getting anywhere'.

Is the service well led?

Direct Health (Stockton on Tees) is a large agency, providing care to approximately 450 people and employing approximately 200 staff at the time of this inspection. The service had a registered manager, with supporting structures in place.

We received consistent feedback from people using the service and staff about the problems caused by the services approach to rotas and covering calls. A relatively low proportion of the services calls (65%) were currently organised as part of a permanent staffing schedule, with the target being 90%. This meant that care coordinators were having to arrange cover for a high number of calls on an ongoing basis, rather than just having to cover gaps and absences. This also meant that staff spent a high proportion of their time covering calls, rather than being able to focus on quality and service improvements. Staff referred to this as 'fire-fighting.' Where routine rotas were in place and people had smaller numbers of regular staff, both people who used the service and care staff reported that this worked well. Where people did not have regular staff people were less satisfied with the service.

Overall, although the service had in place a number of systems to monitor quality and gain feedback from people who used the service, we found that these systems were not effective. For example, people who used the service did not feel that their complaints and feedback resulted in effective actions being taken. We also found that there were still problems with records and medication, despite us asking the service to make improvements during our last inspections.

We found there were appropriate arrangements in place for the recruitment of staff.

We found that people had their needs assessed and support plans were in place. Staff we spoke with were knowledgeable about the needs of the people they supported.

Staff received appropriate training and systems were in place to ensure staff received supervision and appraisals in line with the organisation's policy.

During the inspection we looked at the care records of people who used the service. We found that some support plans were insufficiently detailed and it was not clear if assessments and support plans were being reviewed regularly.

People and relatives we spoke with told us there were copies of care records in people's homes but the level of detail in them varied. Work was ongoing to update care records for people that used the service. We found that people did get continuity with the carers visiting them.

People who use the service were protected from the risk of abuse and felt safe.

Staff received appropriate training but did not receive regular supervision and appraisals.

There was a complaints procedure in place and people were aware of how to raise concerns about the service.

The people we spoke with said they were treated with dignity and respect by the staff.