Lifeways Community Care (New Barnet)

About the service: Lifeways Community Care (New Barnet) is a domiciliary care service. It provides personal care to people living in their own flats within supported living schemes as well as people living in their own homes in the community. The service supports people with learning disabilities, acquired brain injuries,

physical disabilities, autism and mental health needs.

Not everyone using Lifeways Community Care (New Barnet) receives the regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. The service was supporting 12 people with personal care at the time of inspection.

People's experience of using the service and what we found.

All staff had received appropriate infection prevention and control training, including how to put on and take off their Personal Protective Equipment (PPE) in line with guidance.

There was enough PPE available and staff were provided with individual hand sanitisers. Social distancing measures were in place.

People and their relatives were supported to remain in touch via a range of methods, which were assessed on an individual basis.

The registered manager told us there had been some challenges in accessing routine testing for COVID-19, however, this was in the process of being resolved. A comprehensive infection prevention and control policy was in place and had been updated specifically in relation to COVID-19.

Rating at last inspection

The last rating for this service was Good (published 24 May 2019).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in response to concerns received about infection control procedures. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. We found no evidence during this inspection that people were at risk of harm from these concerns.

Please see the safe section of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lifeways Community Care (New Barnet) on our website at www.cqc.org.uk.

Follow up

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

People’s experience of using this service: During the inspection we observed people and the way in which they were supported. People knew the support staff that supported them and were seen to be at ease and comfortable in their presence.

Support staff knew people well. We saw support staff communicate and respond to people using ways and methods which people understood, especially where some people were non-verbal.

Relatives told us that their relative was safe and supported appropriately by support staff. Care provision was good and people were supported to access the community and participate in activities as they wished.

Risk assessments in place were comprehensive and person centred. Assessments provided clear guidance and information to support staff on how to minimise identified risks and keep people safe.

People received their medicines safely and as prescribed. Policies in place supported this.

All staff recruited to work for Lifeways Community Care (New Barnet) had been assessed as safe to work with vulnerable people.

People's capacity to make day-to-day decisions had been considered and assessed and the provider was working within the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

We saw that there were sufficient numbers of staff available to meet people’s assessed needs.

Care plans were person centred and gave comprehensive information about the person, their needs and how they wished to be supported.

People were appropriately supported with their meals and where specialist dietary support was required this had been clearly documented. Support staff knew about people’s specialist needs and supported them accordingly.

Support staff told us that they were supported well in their roles. Records confirmed that support staff received regular training, supervision and annual appraisals.

Complaints were investigated and responded to according to the providers policy.

Management oversight process in place monitored the quality of care people received. Issues and concerns were identified and addressed with details of the actions taken recorded as part of the service’s ongoing improvement plan.

Rating at last inspection: Requires Improvement (Report published 1 May 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. At the last inspection we found areas of concern around staffing provision, safety risks associated with people’s eating and drinking needs, medicines administration and management, supporting people to access activities and ineffective management oversight processes. At this inspection we found that improvements had been made to all areas of concern that we had noted. All breaches in regulations had been met.

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

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

Not everyone using this service receives regulated activity. CQC only inspects the service being received by people provided with ‘personal care’, meaning help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. There were 19 people using the service in this respect. This included people living in three supported-living schemes located in Egdware, Muswell Hill and Aylesbury.

The care service has generally been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service has a registered manager. This is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection of this service, in July 2017, we found five breaches of legal requirements. These were in respect of person-centred care, safe care and treatment, staff deployment and support, recruitment procedures, and good governance. Most of the breaches related to care and support at the service’s supported living scheme in Edgware. The service was rated ‘Requires Improvement’ and we served an enforcement warning notice for the governance breach on the provider. They sent us an action plan in respect of the breaches. We undertook this inspection to check that the action plan had addressed the breaches. This was also a comprehensive inspection, to make sure the service was providing care that is safe, caring, effective, responsive to people's needs and well-led.

At this inspection, we found improvements in the quality of life of people at the Edgware scheme. Staff engaged better with people there, supported people to undertake activities at home and develop independent living skills, and there was better focus on people’s nutrition and hydration needs. This was underpinned by stronger and more focussed managerial presence there that supported and guided staff better. The standard of care and support at this scheme was therefore more in line with the rest of the service.

Improvements had also been made across the whole service, to ensure staff no longer worked excessive hours, and to the robustness of safety checks when recruiting new staff. Staff were now receiving annual appraisals of their care and support roles.

However, whilst we found some regulatory breaches had therefore been addressed, some remained. This was as a result of findings at the Edgware scheme, primarily due to some people not consistently receiving their medicines as prescribed, and not always receiving the staff allocated to them which sometimes resulted in them not being supported to go out as planned. We also identified concerns around the safety of one person’s care in respect of a choking risk and an injury that had not been responded robustly to. The service’s auditing processes had not identified and addressed these matters, which demonstrated weaknesses in the provider’s governance framework.

Across the whole service, there was positive overall feedback from people using it, relatives, community professionals and staff. This improved on feedback at the last inspection.

Staff treated people kindly and in a caring manner. People’s privacy, dignity and independence was respected and promoted. People were supported to develop and maintain relationships that mattered to them, for example, with friends and family.

People generally received personalised care. Staff knew people well and people generally received the same small team of staff for their care and support.

People received good overall healthcare support. They were helped to access community healthcare services.

People were supported to express their views and be actively involved in making decisions about their care and support. The service was working within the principles of the Mental Capacity Act 2005.

The service was finding ways to involve people and their relatives more in service development. People’s views were listened and responded to, and used to improve the quality of care. There was also clear partnership working with other community professionals.

There was now a management structure in place with capable staff in those roles and no vacancies above team leader levels. Staff felt better supported and hence there was a stronger working culture that focussed on supporting people as individuals.

This is the fourth consecutive time the service has been rated Requires Improvement. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

The service did not have a registered manager at the time of this inspection. However, the manager of the service, who had been in post since January 2017, had recently applied for 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.

We last carried out an inspection of this service in April and May 2017. Breaches of legal requirements were found. We rated the service as Requires Improvement, and served two enforcement warning notices on the provider because of the potential impact on people using the service. These were in respect of safe care and treatment, and person-centred care. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. There were also two warning notices, relating to staffing support and good governance, arising from the previous inspection of January 2017, which were not reviewed at the April and May 2017 inspection.

Our findings at this inspection reflect that, although the provider was operating one service for everyone, people still experienced different standards of care depending on their location. Where scheme manager and team leader arrangements had been stable at one Barnet scheme, there was the most evidence of good care. Improved care was evident at the Buckinghamshire scheme where a new scheme manager and team leader had been working for a few months. But at one Barnet scheme that had been without a permanent scheme manager until just before the inspection, people had been experiencing poor standards of care.

We therefore found that the provider had addressed many of the specific concerns identified in the four warning notices we had served. However, new concerns were identified in relation to the regulations relating to each of the four warning notices, and so the provider remained in breach of those regulations. Additionally, a new breach of regulations was identified relating to fit and proper persons employed. This was because recruitment checks of new staff were not robust enough to ensure they posed no significant risks to people they provided care to.

Some people were not consistently supported to access healthcare services. This applied at two schemes in respect of dentist visits. At one Barnet scheme, two people’s weight was not monitored as per their care plans, resulting in avoidable weight loss for one person and a subsequent dietitian referral. Health professional advice was not followed for this, which undermined their safe care and treatment. For example, after a recent visit to A&E, guidance on supporting the person to have a light diet for a few days was not followed.

Whilst people had comprehensive and individualised care plans, some people at one Barnet scheme received care that was not responsive to their individual needs and preferences. In particular, two people were not being supported to attend planned community activities. The wheelchair for one of them had not been safe to use for three months without being fixed.

There were occasions when people living in Barnet did not receive their assessed levels of staffing, which had potential to compromise their safety, and which impacted on people attending community activities.

Most staff treated people kindly and with respect. However, this was not so for someone we met at one Barnet scheme who experienced poor care in several different ways. Where some people needed help to communicate at this scheme, this was not consistently taking place. There was occasional use of agency staff across the service. These matters were not helping positive and caring relationships to develop.

There were inconsistencies with ensuring everyone was supported with managing their medicines and keeping medicines and household chemicals locked away where needed.

Records relating to the care of people and the management of the service at one Barnet scheme were not consistently accurate and complete. For example, one person’s care record for the whole day was found to have been completed by lunchtime of our visit. Records of injuries and bruises to people had not been consistently completed there, which meant matters of concern were not always reported as incidents. This failed to help keep people safe.

At the Barnet schemes, some staff were working excessive hours. This included shifts that were 24 hours or longer. This put people at risk of receiving unsafe care.

Whilst most staff were well-trained and supervised, many staff due annual performance appraisals had still not had them. This meant there was inconsistent support of staff to ensure that people received effective care.

There were improved systems of handling and auditing complaints. However, there were inconsistencies with ensuring all complaints were recognised and investigated thoroughly.

The provider had failed to identify and address many of the concerns we found during this inspection. The breaches we identified in respect of person-centred care, safe care and treatment, staffing, and fit and proper persons employed, showed us the provider’s quality and risk auditing processes were not consistently effective.

Nonetheless, some people received good quality care. This was evident through feedback from relatives and staff, and from our visits to schemes that had a stable management teams.

Whilst this inspection identified significant concerns for the care and welfare of some people at one scheme in Barnet, information subsequently received up until the time of drafting this report indicated improving care of people at that scheme. This included information from the new scheme manager, the manager of the whole service, and local authority staff who had visited the scheme recently. This has reduced the severity of our regulatory approach in response to what we found at this inspection.

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

We undertook this focused inspection of 20 and 21 April and 3 May 2017 to check that the provider had followed their plan and to confirm that they now met the legal requirements relating to the warning notices in respect of safe care and treatment and person-centred care. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lifeways Community Care (New Barnet) on our website at www.cqc.org.uk .

The inspection was also prompted in part by notification of an incident suggesting potential concerns relating to the management of fire safety within one of the supported living schemes that this service provides care at. This inspection examined those risks.

The provider is registered for this service to provide homecare and supported living services to anybody in the community. The service specialises in the care and support of people who have a learning disability. At the time of this inspection the agency was providing a regulated care service to 19 people in their own homes. This included some people living in three supported-living schemes located in both Barnet and Buckinghamshire, and some people receiving stand-alone services in their homes.

The service did not have a registered manager 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. We met with the new manager, who had been appointed just before our previous inspection, as part of our visit to the service.

Our findings at this inspection reflect that, although the provider was operating one service for everyone, people still experienced different standards of care depending on their location. Where service manager arrangements had been stable at one scheme, there was the most evidence of good care. This was not the case for the Buckinghamshire scheme where new managers and a team leader had only recently been recruited, albeit the benefits of the new management input were starting to be seen. We therefore found that the provider had addressed some of the concerns relating to safety and responsiveness as outlined in our warning notices, but others remained and we identified some new safety concerns.

There continued to be errors relating to the safe and proper management of people’s prescribed medicines. This was mostly at the Buckinghamshire scheme where we found that people had not been consistently supported to take medicines as prescribed. However, this was also the case for one person in a Barnet scheme, plus some supporting documents for the safe management of medicines were not always kept up-to-date.

At the Buckinghamshire scheme, the people living there, who were dependent on staff support, were still not often accessing the community, contrary to plans made in that respect. This included one person whose physiotherapist recommended daily walks and whose care plans stated that they liked going out. Records showed they received staff support to go out four times in twenty days just before our visit to their scheme. There was better community support of people at the Barnet schemes.

At the Buckinghamshire scheme, there were no documented checks of hoists, slings, wheelchairs and bedrails since October 2016, despite two people using these and procedures generally requiring monthly checks. There remained no evidence of a professional check of the safety of the mobile hoist that had been used there for a number of months. No-one had been supported to have their weight checked since October 2016, despite one person’s care plan requiring this monthly. One person there required staff trained in stoma care, but most staff did not have that training. People’s risk assessments were not up-to-date, and did not exist in respect of bed-rail use. This all meant that safety risks for these people may not have been identified and minimised.

There remained occasional infection control concerns including bodily fluid stains on one person’s bedding and ingrained food stains on another person’s wheelchair belt buckle. However, good standards of cleanliness were usually observed during our visits.

Improvements had been made with ensuring staff working with people at risk of choking had had their competency assessed in respect of providing meal support. At the Buckinghamshire scheme, staff had received additional training in that respect, and we saw plans to provide this for other applicable staff. Individualised guidelines on how to support people to eat safely were easily accessible where needed. People received blended food in its constituent parts, which enhanced their meal experience, and some had adapted equipment to enable greater independence.

There have been improvements to the number of staff who have had a medicines competency check within the last year, and there were plans to complete this process. There have been reductions in the amount of agency staff used overall, and the amount of hours worked by each of the small staff team at the Buckinghamshire service.

There was good liaison with healthcare professionals to reduce some people’s medicines and improve on quality of life. We also noted little use of sedative PRN (as-needed) medicines that some people had, which indicated good care provision.

There was evidence of ongoing fire safety checks by staff at each scheme. People had up-to-date and individualised fire evacuation plans, and most staff had up-to-date fire safety training. There were ongoing reviews of fire safety at each scheme in light of the recent notification suggesting potential concerns relating to the management of fire safety.

There remained two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 out of the two regulations we inspected against. You can see what action we told the provider to take at the back of the full version of the report. There were four other breaches of regulations identified at our last inspection; these will be followed up at our next inspection.

The provider is registered for this service to provide homecare and supported living services to anybody in the community. The service specialises in the care and support of people who have a learning disability. At the time of this inspection the agency was providing a regulated care service to 27 people in their own homes. This included some people living in four supported-living schemes located in both Barnet and Buckinghamshire, and some people receiving stand-alone services in their homes.

The service had a registered manager 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. However, the registered manager was not present as they had informed us of leaving the role shortly before our visits. A new manager had been appointed and was present from the start of our visits.

Our findings at this inspection reflect that, although the provider was operating one service for everyone, people experienced different standards of care depending on their location and recent local management arrangements. Where service manager arrangements had been stable at one scheme, there was positive feedback and evidence of good care. However, this was not the case for the two Buckinghamshire schemes where there had been a number of changes of service manager and team leaders and where no-one was in some of these roles at the start of the inspection.

We found that the service was not well-led. The service manager and team leaders resources needed to run the service were not consistently available, particularly in the few months leading up to this inspection. Therefore, whilst there was a detailed plan to address breaches from our previous inspection, the plan had not been properly implemented. Whilst there were good systems of auditing quality, these had not been properly undertaken where there were reduced management resources. Monitoring systems by which the provider could assess service risks were therefore incomplete and inaccurate. This may have been a factor in the breaches affecting people’s safety and welfare that we identified at this inspection.

Whilst there were good systems to identify and address risks to people’s safety, there were occasions where these were not properly followed. At one Buckinghamshire scheme, despite a choking incident there a year earlier, current staff did not have training on choking risks and supporting people to eat safely, and could not demonstrate that they were following individualised eating support guidelines. There were also shortfalls there in ensuring that some moving and handling equipment was safe to use, and with ensuring staff there had epilepsy training.

People at the above scheme, who were dependent on staff support, were not often accessing the community, contrary to plans made in that respect and despite them having designated cars for that purpose. Additionally, some staff there worked long hours and many days without breaks, which may have undermined their ability to provide consistently safe care.

Many people were safely supported with managing their medicines. However, staff competency checks were not in place for a number of staff. Medicines were not properly and safely managed at one Buckinghamshire scheme. Infection control systems at some schemes were not fully robust.

The service supported people in a number of ways to express their views and make decisions about their care and how the service operated. However, staffing at the Buckinghamshire schemes was not consistently reflecting some people’s preferences.

There continued to be a significant number of staff who were not being supervised regularly. Many staff due annual performance appraisals had not had them. There was insufficient support of staff to ensure that people received effective care.

The service was still not formally sending us information about some allegations of abuse and police matters relating to their care of people. This undermined our ability to effectively monitor and regulate the service.

Where two people sustained serious injuries whilst using the service, these were not properly investigated under Duty of Candour procedures, and so opportunities to demonstrate learning from these were not occurring. However, investigations of some matters such as for safeguarding cases were robust. The service had systems to help protect people from abuse and respond to allegations of abuse.

Although a complaints system was in place and matters were investigated, it was inconsistently managed and so it was unclear if people were satisfied with responses.

The service was caring. Most feedback about staff indicated that they treated people kindly and with respect, and we saw this to be the case. People were supported with health professional appointments and with their health and nutritional needs.

There were overall five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the 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.

The provider is registered for this service to provide homecare, supported living and extra-care services to anybody in the community. The service specialises in the care and support of people who have a learning disability. The service was split into four geographical areas, each led by a manager. Within these areas were a small number of supported-living schemes and some people receiving stand-alone services in their homes. At the time of this inspection the agency was providing a regulated care service to 29 people in their own homes.

The service had 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 and associated Regulations about how the service is run.

People using the service and their relatives provided some good feedback about the service. However, this was not consistent across the various schemes.

We found that the standard of services people received was inconsistent. Despite effective management of risks to people at most schemes, we found significant safety and infection control risks at one scheme, plus ineffective systems of identifying these and taking appropriate actions as a result. People at this scheme also experienced disrespectful approaches from staff and a lack of support for maintenance issues. There was a wider inconsistency across the service for staff respecting people’s privacy.

We found that some people did not have always have enough staff to support them, which may have impacted on their safety and how well their needs were met.

Whilst the quality of staff training was positive, staff did not always receive training relevant to their care roles. There was also varied support and supervision of staff across the schemes that sometimes undermined effective service delivery.

The provider used a number of in-depth quality-auditing systems. However, we found that these were not consistently effective at identifying and addressing risks to the health, safety and welfare of people. For example, some schemes had been lacking sufficient management input.

The provider failed to notify us of a number of allegations of abuse and police involvements relating to their support of people using the service. This prevented us from monitoring the service effectively.

Whilst complaints were encouraged, there was not a fully effective system for handling and responding to complaints.

However, people experienced good services in some respects. People were supported to maintain good health and eat healthily. The advice of community healthcare professionals was appropriately sought and acted on. People’s medicines were properly managed so that they were supported to take them safely.

Most people received personalised care that was responsive to their needs. For example, staff supported people to undertake planned activities at their schemes and in the community.

The service ensured that people were ordinarily supported by the same small team of staff. This helped to develop positive, caring relationships.

We found that most people and their relatives were involved in making decisions about care and support. The ethos of a person-centred, user-led approach by which to lead meaningful and fulfilling lives was being encouraged.

The service worked in line with the principles of the Mental Capacity Act 2005 in terms of people’s consent to care and acting in their best interests where appropriate.

The service had suitable systems for identifying and responding to allegations of abuse. Recruitment processes ensured that new staff were of good character and suitable to work with people.

There were overall three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we have told the provider to take at the back of the full version of this report.

The agency had a comprehensive safeguarding policy. There was documented evidence that all care staff had been provided with training in safeguarding adults. Managers and care staff we spoke with were knowledgeable regarding action to take in response to incidents or allegations of abuse. Allegations of abuse known to the provider had been reported to the responsible safeguarding teams and the Care Quality Commission.

The agency had co-operated with safeguarding investigations carried out by the local authorities. However, we noted that there was delay in sending out documentation to a relative as agreed in an action plan we examined. There was no written risk assessment for a carer implicated in abuse who was not suspended. There was also no documented record that a senior staff member overseeing a carer implicated in abuse had received regular formal supervision to ensure that they were supported in their role of caring for people who used the service. The manager explained that there had been a shortage of senior staff.

People who used the service had been assessed and their choices and preferences were recorded. Risk assessments had been prepared for people. Care plans were in place and the care provided was monitored by the manager and senior staff. The manager and six staff we spoke with were aware of the needs of people and the care to be provided. The agency had a policy and procedure for the administration of medication. Care staff responsible for assisting with medication had been provided with medication training.

Staff informed us that there was good communication and they felt supported by their managers. Staff had been provided with the necessary training to enable them to perform their duties. Staff we spoke with were knowledgeable regarding their roles and responsibilities.

The agency had a complaints procedure. People who used the service and a relative we spoke with knew who to talk to if they were unhappy with the services provided.

Care and support plans were up to date and regularly reviewed. A relative said 'the staff really are very caring. They do care about what they do.' Plans and risk assessments were individualized, focusing on people's safety and welfare. Daily records were kept of care delivered and regularly reviewed. People could access health and other professionals when needed. People's needs were assessed, planned for and delivered in line with their individual care plan.

Relatives felt their family members were safe and staff knew the safeguarding policy and procedure. They understood the different types of abuse and knew to contact the manager or local safeguarding team if they had any concerns.

The service had good systems in place to check on the quality of care delivered. However there was evidence that formalised support for staff was limited. Staff were not all receiving appropriate professional development.