Archived: London Borough of Waltham Forest, Independent Living Team

London Borough of Waltham Forest, Independent Living Team provides personal care and reablement support to people for up to six weeks to enable them to regain their independence and confidence.

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. At the time of the inspection, 14 people were receiving personal care.

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

Risks to people’s specific health conditions were not always explored and recorded in their care records. This put people at risk of harm. Accident and incident records did not include learning outcomes to prevent future occurrence.

People’s care plans lacked consistency and their needs in relation to their sexual orientation and gender expression were not recorded. This meant people may not have always received care that met their personal needs. The complaints’ records were not always consistently completed. The provider’s auditing systems were not always effective,

People and relatives told us they felt safe with staff. They were satisfied with staff punctuality. Staff knew risks to people and knew how to safeguard them against the risk of harm and abuse. Staff followed safe infection control procedures.

People’s needs were assessed before they started receiving care. People told us their individualised needs were met by staff who received regular training and supervision. People’s dietary needs were met, and staff encouraged them to regain their independence and confidence. People told us they received appropriate support to access healthcare services.

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.

People told us staff were caring and kind and treated them with dignity and respect. People’s needs in relation to their protected characteristics were met by staff. Staff encouraged people’s independence. People told us they were supported by same team of staff.

People told us they were involved in planning their care and were part of the care reviews. People’s personal needs were met by staff who had a good understanding of their background history, likes and dislikes. People told us they felt comfortable in raising concerns and were satisfied with the complaint’s process.

People were happy with the service and told us they would recommend the service to others. They told us the management was approachable and sought their views about the quality of the service.

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 17 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made but were not enough and the provider was still in breach of a regulation. The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last four consecutive inspections.

This service has been in Special Measures since 4 March 2018. 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 follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified a breach in relation to good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

The service was last inspected in June 2018 when we identified the service had not yet met breaches of regulations identified in January 2018. We required the provider to submit regular updates on their action plan to address our concerns.

At this inspection we found the provider had made progress since our June 2018 inspection. However, the service was not operating at full capacity and issues with the quality of care plans, risk assessments and deployment of staff remained.

London borough of Waltham Forest – Independent Living Team is registered to provide personal care to people in their own homes. They provide up to six weeks support to people to help them regain their independence and confidence. At the time of the inspection in October 2018 they were providing personal care support to approximately 20 people. The provider told us their target operating capacity was 45 people.

There was a registered manager in post. 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.

Risks to people were identified as part of the assessment process. However, the measures in place to mitigate risks were not always clear and not all risks had been subject to a risk assessment. The service was not supporting people to take medicines at the time of this inspection so we were not able to evaluate if they had made progress in this area.

The provider told us they had made significant improvements in terms of staff deployment. Although there were now fewer missed visits, staff punctuality was poor and people experienced a lack of continuity in their reablement officers. Despite operating well below their usual capacity, the service was unable to offer people fixed times for their care and did not demonstrate a person centred approach to scheduling.

The provider had made improvements to their referral and assessment process. People and referring agencies now had much better information about the nature and scope of the service. Assessments were completed in a timely manner and people told us they were involved in the process. However, although there were improvements in terms of capturing information about people’s personal history, care plans continued to lack detail about how staff needed to support people to achieve their goals. Information about people’s health conditions and the impact these had on people’s care was not consistent and was not always clear. The service was not consistently exploring the impact of people’s sexual or gender identity, religious beliefs or cultural background on their care preferences. We have made a recommendation about including these aspects as part of the assessment and care planning process.

The provider had strengthened their governance and quality assurance systems. However, they were not yet operating effectively and had not always identified issues with the quality and safety of the service.

The provider collected feedback from people at regular intervals but did not always capture negative feedback as complaints. Complaints were investigated and responded to in line with the provider’s policy, but as the systems did not include negative feedback some issues had not been identified by thematic analysis. We have made a recommendation about complaints.

People told us staff treated them with kindness and compassion. Staff told us the provision of additional time when they visited someone for the first time helped them establish positive, caring relationships.

Staff were knowledgeable about safeguarding adults from avoidable harm and abuse. People told us they felt safe with their reablement officers. Staff reported concerns and records showed incidents were investigated and responded to appropriately. Staff told us the office now responded promptly to any issues they raised and we saw reviews were taking place in a timely manner. The service was embedded within the local authority and we saw staff made onward referrals for additional services where this was appropriate.

Staff received the training they needed to perform their roles. The provider had identified gaps in training and we saw training sessions had been booked to ensure staff were up to date with their training requirements. Staff told us they received regular, supportive supervisions. The provider had identified the issues we found with supervision records and was implementing changes to supervision practice to address them.

People receiving a service were offered choices by their reablement officers. The service worked within the principles of the Mental Capacity Act 2005. Where concerns were identified about people’s capacity to consent to their care appropriate assessments of their capacity were carried out.

Staff spoke highly about the registered manager and told us she had achieved real change in the service. Staff told us they now felt valued as part of the team. There were regular staff meetings which were used as an opportunity for development and gave staff a forum to provide feedback about the service. The registered manager was a member of various networks and groups to ensure they stayed up to date with best practice. The provider had changed their senior leadership structure to ensure appropriate operational oversight of the service.

We found continued breaches of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding person centred care, safe care and treatment, staffing and good governance. Full details of a regulatory response are added to reports after all appeals and representations have been completed.

Although the service had made improvements, the rating for the ‘safe’ domain remains ‘inadequate’ and therefore the service remains 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.

Following the inspection in January 2018 we met with the provider and asked them to complete an action plan to show how they would make the improvements required to the service.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements for safe care and treatment and person centred care. This report only covers our findings in relation to those requirements. We inspected the key questions: Is the service safe, and is the service responsive? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk

London Borough of Waltham Forest, Independent Living Team is a domiciliary care agency. It provides personal care to people living in their own houses and flats. It provides a service to adults. The service is designed to provide short term support to people to enable them to achieve independence and regain skills they may have lost following a change in their circumstances, such as an admission to hospital.

The service is required to have a 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 have received an application from the interim service manager to become registered with us.

The provider had failed to take effective action to improve the safety of the service. Risks had not been appropriately identified and measures in place to mitigate risks were unclear and insufficient. Staff did not have access to all the information held by the service about how risks were mitigated.

People told us they were not fully involved in their assessments and writing their care plans. Relatives told us they were involved. The quality of care plans had not improved. They remained task focussed and did not include information about people’s preferences or guidance for staff about how to support people to achieve their goals. Care plans were not completed in a timely way which meant staff relied on commissioning referrals for information about how to meet people’s needs.

The service was not providing support to people who needed help to take their medicines.

Staff knew how to raise concerns that people were being abused. The safeguarding lead in the borough now felt confident staff understood their role and responsibility in relation to safeguarding adults. People told us they felt safe with staff.

The service had not directly recruited any new staff. Although we did not inspect staff deployment as the dates of the warning notice have not passed, people and staff told us issues with scheduling and timekeeping remained.

People told us staff followed good hand hygiene practice and we saw personal protective equipment was available for staff.

Record keeping around incidents had improved and the service was able to show where actions had been taken in response to incidents.

People knew how to make complaints. Records showed complaints were responded to in line with the provider’s policy.

The service had clarified the referral criteria so it was clear to referring agencies the service was not suitable for people approaching the end of their lives.

We identified two continued breaches of regulations regarding safe care and treatment and person-centred care. We require the provider to send us regular updates on the actions taken to address these concerns.

The overall rating for this service remains ‘inadequate’ and the service therefore remains 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.

The service was last inspected in July 2016 when we identified breaches of three regulations regarding person centred care, staff training and support and good governance. We asked the provider to complete an action plan to show what they would do by when to address these breaches and improve the key questions of Effective, Responsive and Well-Led to at least good.

Although the provider had taken action to address the concerns around staff training and support, breaches of regulations regarding person centred care and good governance continued. We found additional concerns regarding risk management and medicines and the service had not followed the action plan submitted to us.

The reablement and support at home team is registered to provide personal care to people in their own homes. They provide up to six weeks support to people to help them to regain their confidence and independence. At the time of our inspection in January 2018 they were providing support to approximately 100 people.

The registered manager had left the service in December 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. The service had just appointed a new team leader who told us they were going to apply to register as manager.

Risks to people during receipt of the service, and in particular in relation to their medicines, had not been appropriately identified or mitigated against. Risk assessments had been completed, but these delegated actions to mitigate risk to people’s relatives and did not inform staff what they needed to do to keep people safe. There was insufficient information about people’s medicines to ensure they were managed in a safe way.

People told us they felt staff had to rush, and did not attend at specific times. Staff told us they were unable to complete aspects of their work because they did not have capacity. Schedules for reablement officers were compiled in a way that meant it was impossible for them to deliver care on time. There were not enough staff deployed to ensure people’s needs were met.

Care plans were not personalised and did not reflect people’s needs and preferences. We saw generic templates were in use and people did not feel involved in the process of needs assessment and care planning. There was limited information about people’s dietary needs and preferences, and care plans did not contain information about how people’s healthcare conditions affected their support needs. There was some information about people’s culture and background, but there was no information about the impact people’s personal circumstances had on their experience of care.

The management and governance structures had not operated effectively to identify and address issues with the quality and safety of the service. Audits were not completed as scheduled and feedback about the quality of the service was not reviewed. There was no analysis completed of call monitoring data, complaints or incidents to ensure lessons were learnt.

People and staff told us their relationships were affected by inconsistent rotas, changing times and staff. People told us individual reablement officers were kind and treated them with respect.

Staff were recruited in a way that ensured they were suitable to work in a care setting. Improvements had been made to staff training and support. Staff received the training and supervision they needed to perform their roles.

The service worked well with other services to ensure people received multi-disciplinary support to meet their needs. The service made onward referrals to other services when people needed ongoing support. Staff had clear information about other services available to people and knew how to make referrals.

People provided consent to their care and treatment and the service worked within the principles of the Mental Capacity Act 2005.

The service was going through an organisational restructure and had clear plans in place for the future development and transformation of the service.

We found breaches of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding person centred care, safe care and treatment, good governance and staffing. We found one breach of the CQC (Registration) Regulations 2009. We made a recommendation about ensuring people’s personal characteristics were reflected in care planning. Details of our regulatory response are added to reports after all appeals and representations have been completed.

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.

At our last inspection the service was non- compliant in supporting staff but they became compliant before this inspection.

London Borough of Waltham Forest Reablement & Support at Home Team is a service that supports people in their own homes to achieve their independence within six weeks of support. At the time of our inspection, 110 people were using the service

The service should have a registered manager. The current interim manager was in the process of applying to 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.

People were kept safe while using the service. Staff understood how to report abuse and were proactive in doing this at the service. The service was based at the council and the local safeguarding team was based there as well and provided support to staff. Some staff were not aware they could contact the CQC with safeguarding matters.

Medicines were not administered by staff at the service. A new medicines policy had been introduced to ensure staff were aware of the level of support they could provide to people with their medicines. This was now being followed by staff.

Risk assessments were carried out to ensure people’s home environment was safe and to check any equipment in their home was safe. Reablement staff told us that if the risk assessment had not been performed before they arrived to start support they would check for risks and inform the office. This helped to keep people safe.

The risk of infection was minimised as staff wore protective clothing. However senior reablement staff were concerned about the risk of cross infection where staff did not change their uniforms after leaving people’s homes with an infectious disease. We have made a recommendation about reducing the risks of cross infection from staff uniforms..

Recruitment was carried out safely and we saw that the service carried out regular criminal records checks every three years to ensure people were cared for by staff of good character.

Staff told us they felt supported as they could approach the interim manager, head of service and colleagues for advice. Staff received an annual appraisal but staff were not receiving regular supervision and training to support them in their role. Staff told us through their years of experience they felt they were good at their job and people told us that staff were good at what they did.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and made sure to obtain people’s consent before providing care. However there were no records of recent training in the MCA.

Staff were very passionate about their job and people and their relatives told us that staff were very caring, kind and patient. People’s dignity and privacy was also respected by staff.

People’s care plans were not person centred. People were set reablement goals which were generalised and sometimes covered many other goals. Furthermore, how staff were to enable people to achieve their goals was not clear. Staff told us they felt more information could be written to explain how to support people to be independent.

Records showed that the level of detail written in people’s care plan was limited and more information was recorded on the service computer system.

We have made a recommendation in following best practice on writing care files.

People were cared for by staff who were prompt in meeting their needs, for example where they had identified if changes in support were required. Staff recorded their observations and people received regular reviews of their care so they were aware of their progress.

People did not feel that the times staff arrived met their needs but staff explained they attended to higher risk people which meant other calls may be late. We have made a recommendation to meet people’s preferred time slots.

Quality assurance was not robust at the service. Previous audits had stopped and there were no recorded quality checks of returned care plans. Spot checks were not being consistently recorded by senior staff.

Staff spoke positively about the management of the service and of the new interim manager. Staff found that good practice and experience was being shared which boosted morale.

We found three breaches of the regulations.