Archived: Saffron Care Agency

We met with the provider to confirm what they would do and by when to improve the service. The number of people who used the service had decreased from 260 to 156 people. The registered manager was receiving support from the organisation who sub-contract packages of care to them and the local authority quality assurance and improvement team (QAIT). Despite this support, this inspection has shown widespread and significant shortfalls, and some deterioration, in the service. The only improvement made, that has had a positive impact, was to staff recruitment.

Saffron Care Agency is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults and younger adults. Not everyone using Saffron Care Agency receives a 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. At the time of this inspection the service was providing care and support to 156 people.

The service had a registered manager who was also the provider. 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 received concerns from people who used the service, staff and the local authority. In response to those concerns we brought forward this unannounced inspection. Prior to us starting this inspection the local authority placed the service back into a multi-agency safeguarding process due to the concerns they had received. We also shared our concerns with the local authority commissioners and safeguarding team. Concerns related to late visits and people being rushed during their visits, lack of staff training, medicines not being administered appropriately, poor communication and lack of response to complaints, and poor staff attitude.

People who used the service were still not safe. We looked at people’s visit records and found staff were not always recording the time they arrived and left visits. This meant the registered manager could not assure us that visits were being carried out as agreed. We found examples of people being rushed, not getting their full visit time, and care being missed. Incidents that should have been reported as safeguarding alerts had not been sent to the local authority without delay. People did not always receive their medicines as prescribed.

When people’s regular staff were not working, staff who carried out visits didn’t always know people or how to meet their needs. We found examples of staff being expected to use equipment when they had not received appropriate training. This included training in how to put on support stockings, using a hoist, catheter care, and supporting people with their oxygen and nebulisers. Some people told us they felt unsafe. One person said “I have issues relating to my safety and the training or lack of training of carers on using my hoist”.

People told us when their regular care staff were not working, they did not receive the same caring service. One person commented “Some of them are very aggressive, some patronising”. People’s preferences were not always listened to and respected. Where people had asked for certain staff not to support them, this was not always respected. Several people told us some staff who visited them didn’t speak to them. One person told us this made them feel sad as they liked to have a chat.

People’s complaints were still not taken seriously, explored thoroughly or responded to. We found complaints that hadn’t been recorded correctly. Complaints records did not contain clear information relating to investigations, outcomes and action taken in response to the complaint. The compliance manager had delegated actions to team leaders and field trainers to resolve issues. We found these actions had not been taken.

Some people still didn’t receive person-centred care because some staff were not aware of their needs before visiting them for the first time. The management had discussed ways of getting information out to staff in September 2017 but staff told us they still didn’t receive information. People’s care plans were still not always reviewed and updated to reflect their current needs. Staff told us there was not enough time for team leaders to update care plans due to them carrying out other duties.

People were still placed at risk because there continued to be a lack of leadership, governance and managerial oversight of the service. People and their relatives told us the service was not well managed. Comments included “This company is not well led. You can talk to (registered manager’s name) and he promises things will be sorted out and they aren’t” and “The service isn’t learning. The company is poor and lets down some of the good carers they have”. Other people told us they were happy with service they received and felt some improvements had been made.

People and staff told us there was still a lack of communication. Staff we spoke with were passionate about their work and knew changes needed to be made but were frustrated by the organisation. Staff commented “Things have got worse not better” and “it’s so badly run”. Staff gave us examples of being spoken down to and not treated equally. When staff had raised concerns these were not taken seriously and action was not taken. Staff told us this had impacted on their morale and staff had left the service as they were unhappy.

The registered manager said he would take actions following the previous inspection. They told us a number of actions had been completed but we found there were ongoing issues which are described throughout this report. Quality assurance systems did not ensure people’s individual care needs were met, risks were minimised or care was delivered to keep people safe.

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

The overall rating for this service is ‘Inadequate’ and the service continues to be 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.

At our previous inspection in October 2015, the provider was meeting all of the regulations.

The service had a registered manager who was also the provider. 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 received concerns from people who use the service, staff and the local authority. In response to those concerns we undertook this unannounced inspection which commenced on 12 September 2017 an ended on 25 September 2017.

Prior to us starting this inspection, the local authority placed the service into a multi-agency safeguarding process due to the concerns they had received. We also shared our concerns with the local authority commissioners and safeguarding team. These concerns related to missed and late visits, poor standards of care, medicines not being administered appropriately, allegations of financial abuse, and the registered manager’s lack of response to complaints.

We found significant concerns which meant some people did not always receive their care as planned and were placed at risk of harm. Some people’s packages of care are currently being reviewed by the local authority commissioners. In addition, the local authority quality monitoring team are working with the registered manager and staff to support them to bring about improvements. The registered manager made a voluntary agreement with us to stop taking new packages whilst the required improvements are made.

People had not received appropriate care and support. We found evidence that people had experienced missed visits. People were not always receiving their calls as planned. For example, one person told us “they usually come about 6.00pm to get my tea, the other evening it was about 9.50pm”. Visits were not planned to allow for the gap between medicine doses or meals. Some people told us that staff did not stay for the length of time they were supposed to and they felt rushed. One person said “I should have 45 minutes. Some care staff rush me and at lunchtime some are only here 10 minutes.” Staff told us they had to shorten visits as they had too many people on their rota and no travelling time in between. This showed the deployment of staff was not effective to ensure that people received their call as planned.

People did not always feel safe. People did not always know who would be visiting them or when they would receive a visit. Some people felt unsafe as staff did not know how to meet their needs. For example, one person said “My biggest worry is that some carers do not know how to handle my sling and hoist and I have had to point out to them what they are doing wrong”. Incidents that should have been reported as a safeguarding alert had not been sent to the local authority. People did not always receive their medicines as prescribed. The registered manager had not carried out required pre-employment checks to ensure staff were suitable to work with people.

We received mixed views from people and relatives we spoke with in regards to staff training. Some people and relatives felt staff were well trained, whilst others told us that care staff needed more training on delivering care. Some staff felt supported but others felt support needed to be improved. Team leaders had observed staff’s care practice. However, our findings during the inspection showed the checks completed on staff’s competency had not identified and resolved these issues.

People and relatives gave us mixed views regarding the staff working for the service. Some people told us staff were not caring towards them and they were not always treated with dignity and respect. Several people told us they had asked for staff members not to visit them but they had been again. People did not always receive care and support from staff who knew them. People told us they were unhappy with the lack of continuity of care staff. Where people had expressed a preference in relation to the gender of care staff who supported them, this was not always respected. Other people told us they were very happy with their care staff.

People did not always receive consistent, personalised care and support. Several staff we spoke with told us they would like more information about people so they could provide better support. For example, a staff member told us when people started to use the service, their needs were not always communicated to them before their first visit. One person spoke about the occasions when they had staff who were new to them. They said “I have to tell them what to do”. People’s care was not always reviewed and updated to ensure their care was still appropriate. This placed people at risk of receiving inappropriate care and support.

People’s complaints had not been taken seriously, explored thoroughly and responded to in good time. We found numerous examples of people making complaints that had not been resolved by the registered manager. The registered manager told us they were aware that verbal complaints had not always been logged. During the inspection, they amended their complaints policy and introduced a concerns form.

There had been a lack of leadership, governance and managerial oversight of the service. The registered manager was not aware of many of the issues we identified. However, after our initial feedback, when we returned to the office they told us about the actions they had already taken and their plans to make the required improvements. This included employing a compliance manager and rota co-ordinator who were due to start in October 2017; putting a computerised monitoring system in place to make sure people received their visits; and giving team leaders protected time to carry out their role. The local authority quality monitoring officer had already visited the service to start working with the registered manager.

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

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At our previous inspection in June 2014 we also had identified that the provider did not have an effective system in place to ensure that records were accessed promptly. At this inspection we found improvements had been made.

We spoke with the Registered Manager. We reviewed staff training records and access to records.

We considered all the evidence we had gathered under the outcomes we inspected. We considered our inspection findings to answer the questions: Is the service safe and effective?

This is a summary of what we found.

Is the service safe?

The Registered Manager told us they had recently employed a Training Manager to work between 24 and 30 hours per week. We saw that most staff had completed training updates in safeguarding, manual handling, infection control, health and safety, medication, dementia, food hygiene and first aid. Any staff that had not yet completed training were booked on courses within the following month. This meant that staff were appropriately supported in relation to their responsibilities. This enabled them to deliver care and treatment to people safely and to an appropriate standard.

Is the service effective?

Team leaders had a key to the office and locked filing cabinets so they were able to access records when they needed them. The Registered Manager told us that all the information about the agency was now stored on a secure computer server. This meant team leaders had access to the information they needed to ensure people's needs were met.

As part of this inspection we spoke with eight people who use the service, two relatives, the Registered Manager, and nine staff. We also reviewed records relating to the management of the service which included, five care plans, daily care records, training records, and quality assurance records.

Below is a summary of what we found. The summary describes what people who used the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, concerns, and investigations. This reduced the risks to people and helped the service to continually improve. We received some information of concern about the quality of the care being provided. We spoke with the Registered Manager about the concerns. They told us they had taken action to ensure improvements had been made. We found that the areas of concern had been addressed and systems had been put in place to prevent any further reoccurrence. We received concerns that people were not receiving their medicines at the times they needed them and in a safe way. People told us they were happy with the way staff supported them to take their medicines. People confirmed that staff kept a record of the medicines they had administered. We found that medication systems in use meant people had their medicines at the time they needed them and in a safe way.

Is the service effective?

People who used the service told us they were happy with the care they received. Comments included "They do everything they can. They can't do any more', 'I look forward to them coming and enjoy their company' and 'We're in a nice routine. They leave everything where I can find it'. We spoke with staff who told us how they met people's care needs. We looked at care plans and spoke with the people who used the service. This gave us evidence that staff knew people well. People's health and care needs were assessed. Care plan reviews had been carried out to ensure they reflected people's current needs. Staff had not received appropriate training to ensure they were able to deliver care and treatment to people safely. Most people who used the service told us they were confident that staff had the skills and experience to do their job and understood their care needs. Comments included 'they know what they're doing' and 'they know just how to do it'. However, one person commented 'when they start they should have more tuition before they come out'. We looked at the staff training matrix and found that training had expired or there was no evidence that it had ever been completed.

Is the service caring?

Feedback from people about the staff was positive, for example; "I've got to know the staff, they're really good to me' and 'They cheer me up'. When we spoke with staff it was clear they genuinely cared for the people they supported and knew them well.

Is the service responsive?

People's needs had been assessed before they started to receive care. The service carried out an assessment to ensure it was able to meet people's needs. We saw evidence that people's care was adjusted when their needs changed. For example, we went on a home visit to a person whose needs had increased recently. The service had arranged a short term care package. The team leader attended the person's home with the staff to provide extra support and assess the person's needs for their future care package. This meant the person's care needs were met appropriately. We saw the complaints procedure was available in people's care plans. People told us they felt able to speak to the manager or staff if they were unhappy about something. They felt confident that the service would deal with any matters to their satisfaction.

Is the service well-led?

People who used the agency told us they were asked about the quality of the service. For example, people told us how the Registered Manager had carried out one of their visits and checked how things were going. People commented 'I can't think of anything that could be better' and 'they've done well, let's hope they keep up the good work'. The service had doubled in size in the past year. The Registered Manager told us they were aware that they needed the right team in place to support the growth and maintain quality. The service had three team leaders in post at the time of our inspection with a further team leader due to start in July 2014. Staff we spoke with told us they felt well supported. They told us they found the Registered Manager to be approachable. Staff told us they were pleased with the support they had received from the team leaders. Comments included 'they are a nice addition to our team' and 'I know who to talk to if I want something to be done. It gets addressed'. Quality assurance records were not available for us to look at as the Registered Manager was on leave. We returned for a third day of inspection to see the records.

People who used the service told us they were very happy with the care they received. Comments included 'I'm very happy, they do everything they can to help'; 'they're very, very good' and 'so far, so good'.

We found the care plans contained enough detail so care workers knew how to meet people's needs. One healthcare professional told us 'They are happy to work jointly with us and have informed us of issues'.

We had received some information of concern about staff training. We found that some care workers were up to date with their training. Other care workers had not completed training in a number of areas including infection control, first aid, health & safety, fire, food hygiene and medication. This meant that not all care workers had completed training to keep them up to date with current best practice.