Archived: HF Trust - Wiltshire DCA

HF Trust – Wiltshire DCA is a domiciliary care agency providing personal care to 10 people who have a learning disability and/or autism. People lived in a ‘supported living’ setting. Supported living services enable people to live in their own home and live their lives as independently as possible. Not everyone using 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.

People lived in two bungalows and two flats on a site shared with other services managed by the provider. There was also a house in a nearby town which provided accommodation for five people. There were shared facilities available on site which included a day service, an activity hall and administration offices.

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

People were supported by staff who had been recruited safely. All the required pre-employment checks had been carried out. There were sufficient numbers of staff to support people, which included some use of agency staff. Staff rotas were planned in advance so regular agency staff could be booked.

People’s medicines were being managed by staff who had training. Any medicines incidents had been reported to the local authority and we had received a notification informing us of the incidents. The management team continually reviewed the medicines policy and we could see it was discussed in team meetings.

There is an imposed condition on the registration for this service to submit to CQC a monthly report of their audits which we had received regularly. The provider had also carried out quality monitoring audits at the service which identified areas for improvement. Action plans were in place recording who was responsible for carrying out actions and by when. This was monitored by the registered manager and provider.

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 10 October 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about staff recruitment and staff working hours, medicines incidents and some areas of management. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

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.

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.

HF Trust – Wiltshire DCA is a domiciliary care agency providing personal care to eight people who have a learning disability. People lived in a ‘supported living’ setting. Supported living services enable to people to live in their own home and live their lives as independently as possible. Not everyone using 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.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

People had their medicines as prescribed however, some medicines records required updating and more detail was required in others to make them robust. Quality monitoring had been carried out, however it had not identified all the concerns we have found at this inspection. Risks had been assessed and recorded and reviewed regularly. We found two risk assessments that required updating.

People felt safe receiving care and support from suitable staff who had been recruited following the required pre-employment checks. More staff had been recruited since our last inspection, but there was still a reliance on agency staff. Where agency staff were used the service tried to use the same agency staff to provide consistent support.

People were able to access healthcare services and supported to do so by the staff team. Health action plans were in place and a health check was carried out annually. Staff used handovers to communicate with each other and share information. 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. Staff were supported and had been trained in a range of areas. Staff spoke positively about the training they received.

People were involved in their care and support where appropriate. Support was provided to help people maintain relationships that were important to them. People were able to join in ‘voices to be heard’ meetings which were held at the site. This gave people the opportunity to share their views and raise concerns. People told us staff were caring and they were happy with how staff supported them. We observed staff interacting with people and saw that people were comfortable and staff knew them well.

Care plans had been reviewed and were personalised. Staff kept daily records which recorded the care and support that had been given. The local authority was involved in people’s reviews which included health assessments. People were able to access employment and plan their own activities. During our inspection four people were supported to go on holiday.

There was not a registered manager in post. A manager had been appointed and was going through the process of registering. The manager had started following our last inspection and had stabilised the service. They were supported by the provider who maintained oversight of this service.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drives of improvement.

As part of thematic review, we carried out a survey with the manager at this inspection This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people.

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 22 March 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. Following the inspection, we imposed conditions on the providers registration. The conditions required the service to report to CQC each month on areas of concern seen at that inspection. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. The service remains rated requires improvement overall. This is the third consecutive inspection where the service has been rated as Requires Improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. The provider is required to send us information each month following their audits. If we receive any concerning information we may inspect sooner.

Not everyone using HF Trust – Wiltshire DCA 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 this time the service was supporting 10 people under the regulated activity.

This inspection took place on 27 November 2018 and was unannounced. The inspection was planned to follow up on the two Warning Notices that were served following our last inspection in August 2018. The Warning Notices were served against breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance of the Health and Social Care Act 2008 Regulations 2014. This inspection only looked at the three domains that the Warning Notices were associated with. These were the safe, responsive and well-led domains. We did not look at the effective or caring domains during this inspection.

At the last inspection in 6 August 2018, the service was rated Requires Improvement with the safe domain rated as Inadequate. We found four breaches of the regulations in relation to Consent, Safe care and treatment, Good governance and Staffing. At this inspection we found that the service had made some improvements but had not taken enough action to meet the two Warning Notices. We are currently considering what further action will be taken against this service. 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.

At the time of this inspection there was no registered manager in place. A manager was in post from March 2018 and had applied to be the registered manager, however, the decision was taken by the Care Quality Commission to refuse the application in August 2018. 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 saw that risk assessments had been updated following our inspection. However, some of these continued to be generic and pre-empted a risk rather than being specific to a person. This did not indicate an active approach to positive risk taking. Where a risk had been identified, the actions to take were set to pending and to be completed in a year’s time, with no sense of urgency. This did not safely ensure that any actions needed to reduce the risk to people were mitigated in a timely manner.

During our inspection we observed that security was not always managed safely. The keys to four people’s medicines and money were put in a drawer, which was not locked and accessible to people.

Medicines continued not to be safely managed. Although we observed there had been some improvements at this inspection, further improvements were required. Weekly checks were being completed by senior staff, however the audit process was not always effective as the shortfalls identified at the inspection had not been picked up through these checks.

Staffing continued to be an issue for the service. Although the staffing levels were met, these were being maintained on agency staff which compromised the consistency people received. We found that due to the high numbers of agency staffing, people were not always able to attend activities of their choosing.

Care plans had continued to contain generic statements that were not always inclusive. We saw that the reviews of people’s needs and three care plans viewed, continued to need work. Two people continued not to have an end of life plan in place despite being at risk of sudden death due to their health conditions.

Quality monitoring at the service continued not to be robust. The provider sent action plans following the last inspection to demonstrate how they would meet the two warning notices served. The provider stated they would address the concerns and meet the actions by end of October and November. At this inspection we found the provider had failed to complete some of these actions.

The regional manager told us that the majority of staff had now received training sessions on reporting incidents, how to use the electronic reporting system and what they should be recording. Staff verbally showed an increased awareness for the action they needed to take around reporting and managing incidents and ensuring medical advice was sought where necessary.

Improvements had been made to putting in place a more comprehensive handover sheet with a daily checklist for staff to complete.

This inspection took place on 6 August 2018 and was unannounced. The inspection was prompted in part by an inspection of the provider’s residential service on the same site, which has recently been rated as Inadequate. This service shared the same management team, some of the same staff and the same processes and systems. For this reason, we made the decision to inspect this service earlier than we had originally planned. Although short notice is normally given to services providing a domiciliary care service for people, in light of the concerns it was decided it would be unannounced.

At the last inspection in May 2016 the service was rated as Good. At this inspection we found four breaches of the regulations in relation to Consent, Safe care and treatment, Good governance and Staffing. We have served two Warning Notices on the provider in relation to Regulations 12 Safe care and treatment and 17 Good governance. The service is required to achieve compliance within a set timescale or further action will be taken. We have also made a recommendation around opportunities for staff supervision.

The service has been rated as Requires Improvement with the safe domain rated as Inadequate. We will be asking the service for a report of actions of how they will make the necessary improvements and the service will be re-inspected to check this has been done.

At the time of this inspection there was no registered manager in place. A manager at the service had applied to be the registered manager, however the decision was taken by The Care Quality Commission to refuse the application and management of this service. 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 found have the provider and management team at this service failed to meet the requirements of the regulations placing people at risk of receiving inappropriate and unsafe care. Quality monitoring at the service was not robust. There was no effective monitoring or checks made by management and senior management in order to take timely action when shortfalls occurred. The director has implemented some immediate changes to address these concerns but time was needed for the planned actions to be completed before we could judge whether the provider’s actions had been effective in making the required improvements.

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.

People using the service their and relatives confirmed that people did not always receive their allocated care hours due to staffing shortages. The manager and staff confirmed this was true. This had a negative impact on people’s wellbeing with inconsistent support and times when planned activities had to be cancelled.

The manager failed to appropriately report to external agencies when people did not receive their commissioned support hours to ensure that prompt action would be taken to protect people from harm and neglect. This was raised with the manager and senior management at the time of this inspection.

The recording of incidents and accidents, subsequent investigations, actions taken and measures to minimise risks had not been safely managed. We found that not all incidents had been logged or reported to the manager. This meant there was a lack of oversight of what incidents had occurred and the appropriate action and support had not been provided in a timely manner to support people.

Risk assessments did not always contain enough detail to ensure the risks were mitigated or referred to other guidance that staff could read.

Medicines were not always managed safely. We found gaps in medicines administration records (MAR’s) where staff had not signed that they had administered the medicines. One staff member told us this was a recording issue and that people had received their medicines as prescribed.

The service was not working within the principles of the Mental Capacity Act (2005). We found mental capacity assessments and best interest decisions were not consistently completed where people lacked capacity to make specific decisions. We found some examples of restrictive practice, where there was no record of the discussion on how this decision was made or what other options had been considered.

People and their relatives told us they were happy with the care they received, as long as it was the regular staff members supporting them. We saw in one person’s feedback about the service, that they did not feel comfortable with agency staff. One person said some agency staff shouted and weren’t always kind.

There was limited documented evidence available that staff had received regular supervisions and staff gave mixed responses about their opportunity for supervisions. We have made a recommendation that the provider reviews the opportunities available to provide staff with adequate supervision and progression support.

We observed staff respecting people’s personal space and ensuring doors were closed when providing care and knocking on doors and waiting for permission before entering. Staff showed concern for people’s wellbeing and responded to their needs quickly.

Care plans had information about people’s likes and dislikes and how they liked to spend their day. However, the terminology in care plans was at times paternalistic (limits people’s freedom to achieve their own level of independence) and inappropriate when referring to adults. Care plans were not dated when there was a change in the care plan. This meant staff may not be aware of the most current actions. A lack of dates on care plans meant it was unknown when things had been put in place or when peoples’ needs had changed.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law, as does the provider. 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 found the service to be well led.

People told us they felt safe. They were supported to stay safe by staff who understood and knew how to protect people and minimise the risk of harm and abuse. All staff had received training in safeguarding vulnerable adults and were able to explain how they would recognise and respond, should they suspect abuse was taking place. Where risk of harm had been identified assessments had been undertaken and plans put in place to minimise these risks.

People received flexible and responsive care and were supported by sufficient numbers of staff to meet their needs. Staff received training and supervision to enable them to meet people’s needs.

The service followed safe recruitment practices which included appropriate checks prior to staff commencing employment with the service. Recruitment processes were in place that had been followed.

People had access to health care support when required and staff responded to health care issues in a timely manner. People received their medicines safely and accurate records were maintained.

People and their relatives were involved in the development of care plans and were able to express how they preferred to receive care and support. The management team were adaptable to changes in people’s needs and communicated changes to staff.

People were supported to maintain a balanced diet and were involved in menu planning. People were able to make their own snacks and drinks, whilst others received the necessary support as required.

People felt that staff treated them with dignity and were supportive in helping them to maintain their independence as much as possible.

The registered manager had regular contact with people using the service. There were policies in place which ensured people would be listened to if they made a complaint and actions would be taken to resolve the situation.

The provider had robust quality assurance systems in place to ensure the quality of service provision.