Westminster Homecare Limited (Enfield, Havering and Waltham Forest)

Westminster Homecare Limited (Enfield, Havering and Waltham Forest) is a domiciliary care service registered to provide personal care to people living in their own homes in the community. At the time of our inspection 231 people were being supported with personal care.

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

The service assessed risks to people’s safety and wellbeing. There was guidance in place for staff on how to support the person to manage those risks, for example, how to help somebody move from bed to wheelchair or how to support them with eating. Medicines were managed safely.

The service employed enough staff and ensured they were safely recruited, trained and supervised to do their job well.

Care plans were detailed and person-centred and guided staff on how to provide care to the person to meet their needs and their preferences. People were involved and consulted in planning their care.

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.

The service supported people with their health needs. People were generally happy with quality of the service. Although people were overall happy with their care workers a number of people did not like the time their care workers visited. The service was not responsive to people’s choice of times for their care visits, despite providing good care. We have made a recommendation that the service provider make improvements in responding to people’s preferences.

The service had made improvements following the last inspection and although the provider had moved another branch into this branch office increasing the number of staff and people they were providing care to, they had been able to sustain improvements made. There were effective quality monitoring systems in place and the registered manager shared plans for further improvements with us. The service responded promptly to complaints and concerns.

Rating at last inspection and update

The last rating for this service was requires improvement (published 21 November 2018).

At this inspection we found improvements had been made and sustained and the provider was meeting fundamental standards.

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. If we receive any concerning information we may inspect sooner.

At an inspection of this service on 4, 5 and 6 April 2017 we found that some aspects of the management of medicines were not safe and so there was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that the quality assurance systems regarding medicines auditing and the management of staff rotas and late visits were not well managed and so there was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Due to the serious nature of the breaches we took enforcement action against the registered provider. Two warning notices were issued, for breaches of Regulations 12 and 17. Warning notices give the provider a specific time frame in which to improve in the areas identified at the inspection.

On 1 and 7 September 2017 we undertook a focused inspection to check whether the service had met the breach of legal requirements in relation to Regulations 12 and 17, concerning safe management of medicines, quality assurance of medicines and staff rotas, which had resulted in

enforcement action. We found that the service had failed to meet the requirements of the enforcement action we had taken and continued to be in breach of Regulations 12 and 17.

Following that inspection, we wrote to the provider using our powers under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, to ask the provider to send specific information on actions they intend to take to address the concerns that we had raised and by when to improve the key questions of ‘Safe’ and ‘Well-led’ to at least good. An action plan was submitted which detailed the steps they planned to take to make the required improvements.

The local authority for Enfield had placed an embargo on Westminster Homecare (Enfield / Waltham Forrest) following the inspection in April 2017 to prevent the service taking on any new people. The provider also implemented a voluntary restriction on referrals from the London Borough of Waltham Forest until the necessary improvements had been implemented. The provider lifted the voluntary suspension for new referrals from Waltham Forest in January 2018. The London borough of Enfield lifted the embargo place on the service in August 2018 after significant improvements had been noted.

Westminster Homecare (Enfield / Waltham Forest) is a domiciliary care agency. It provides They provide a wide range of personal care options to people living in their own houses and flats in the community. It provides a service to older people, some of who are living with dementia. At the time of this inspection the service was supporting approximately 173 people.

Not everyone using Westminster Homecare (Enfield / Waltham Forest) receives 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.

A registered manager was in post at the time of this 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.

During this inspection we found that the provider had made significant improvements and had addressed the breaches previously identified and was now meeting the regulatory standards.

However, we continued to receive feedback from people and their relatives that timekeeping remained an on-going concern and that people and their relatives did not believe that the service communicated with them effectively especially when care staff were running late or when changes had been made to the care staff they were scheduled to receive. We have made a recommendation around further improving systems and processes when allocating sufficient travel time so that people receive their care call on time.

People received their medicines safely and as prescribed. The provider had implemented robust systems and processes to ensure that medicines management and administration was safe and closely monitored. However, some concerns were noted around the recognition of certain high-risk medicines and their side effects and the documentation around as and when required medication.

The registered manager and provider had introduced a variety of processes which enabled the service to regularly and comprehensively monitor the quality of care provision. Issues and concerns identified were clearly recorded and where improvement and learning were required this had been implemented.

Risks associated with people’s health and care needs were identified through the care planning process. Guidance and information was available for care staff to follow so that people’s known risks could be reduced or mitigated to keep people safe.

Care staff were able to describe the different types of abuse people could experience and clearly explained the steps they would take if abuse was suspected.

Safe recruitment processes were followed to ensure only those care staff assessed as safe to work with vulnerable adults were employed.

Care staff received appropriate training and support to effectively carry out their role. This included induction, refresher training, supervision and an annual appraisal.

People were supported with their nutrition and hydration needs where this was an identified and assessed need as part of the person’s package of care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

The service supported people with their health care and medical needs where required. Where people required additional care and support, appropriate referrals had been made to the relevant healthcare professionals.

Care plans were person centred and detailed and clearly set out the person’s support needs which enabled care staff to deliver care.

People and their relatives told us that care staff were caring and engaged with them whilst supporting them with their needs.

People and their relatives knew who to speak with if they had any complaints or issues to raise. However, most people and relatives told us that they did not feel their complaints were always adequately addressed.

Most people and their relatives knew their allocated care coordinator more than they knew who the registered manager was. The care co-ordinator was the person who was always in contact with them about their care and support package.

This inspection took place on 1 and 7 September 2017. We undertook this announced focused inspection to check that the most significant breach of legal requirements in relation to Regulations 12 and 17, concerning safe management of medicines, quality assurance of medicines and staff rotas, which had resulted in enforcement action, had been addressed. The provider was given 24 hours' notice because the location provides a domiciliary care service and we needed to ensure that the registered manager or someone that could help would be present during the inspection.

Westminster Homecare (Enfield/Waltham Forest) provides support and assistance for people who want to live at home and maintain their independence. They provide a wide range of personal care options and specialise in supporting people with dementia. At the time of the inspection, the service was supporting 298 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. At the time of the inspection the registered manager was not present as they were on leave. The inspection was supported by the deputy manager, deputy director of operations, an operations support manager and a registered manager from another branch.

During this inspection we found that the provider had not adequately addressed these issues and people’s medicines were still not safely managed. Information regarding people’s medicines was not always consistent and we found omissions in signing Medication Administration Records (MAR). One person that was at risk of malnutrition had not been receiving their nutritional supplements as prescribed.

Medicine audits were not always clear and failed to recognise risks to people that may have missed their medicines. Medicines issues were often picked up months after an error had occurred.

We received feedback that there were still numerous late care visits. There had been some improvement in staff rotas and rotas now noted five to ten minutes’ travel time. However, the provider was not ensuring that staff received sufficient travel time and we received feedback that there were still numerous late care visits.

The local authority for Enfield had placed an embargo on Westminster Homecare (Enfield / Waltham Forrest) following the last inspection to prevent the service taking on any new people. However, this was not in place for Waltham Forest referrals and the service continued to accept new referrals from this borough. We spoke with and wrote to the provider who said that they would place a voluntary restriction on accepting any further referrals from Waltham Forest. This means that the service will not be currently accepting new referrals.

We also wrote to the provider using our powers under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, to ask the provider to send specific information on actions they intend to take to address the concerns raised in this report.

At this inspection, we found breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We last inspected the service on 30, 31 August 2016 and 01, 05 and 09 September 2016 and found the service to be in breach of Regulations 12 and 17 of the Health and Social Care Act 2008. Issues we found related to unsafe medicines management, lack of risk assessments especially in relation to high risk medicines, poor timekeeping resulting in people not receiving care at their preferred time and poor governance which did not identify the issues that we found during the inspection. As a result of the issues we found, the Care Quality Commission took enforcement action against the provider and issued a warning notice on 5 October 2016 requiring the provider to immediately address the concerns around Regulation 12 of the Health and Social Care Act 2008.

At this inspection we found that although some improvements had been made in response to the warning notice around risk assessments, the provider had failed to make adequate improvements to ensure safe medicines management and was not compliant as per the requirements of the warning notice. The provider was also found to be in continued breach of Regulation 12 and 17, in relation to late visits and poor management oversight.

Westminster Homecare Ltd (Enfield/Waltham Forest) provides personal care services to people living in their own homes. They provide a wide range of personal care services and specialise in supporting people with dementia. At the time of this inspection the service was providing personal care services to 321 people living in Enfield and Waltham Forest.

A registered manager was in post at 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.

People did not always receive their medicines safely and as prescribed. At the last inspection in August 2016 we found numerous gaps on medicine administration records (MAR’s) which meant that we could not confirm whether people had received their prescribed medicines. We also found that where people had been prescribed high risk medicines, these had not been risk assessed, which meant that care staff were not provided with the appropriate information in order to mitigate or reduce the risks associated with the identified medicine. At this inspection we found that although comprehensive risk assessments had been completed in relation to people’s identified health and care needs, medicines were not managed and administered safely. Where medicine audits focussed on identifying gaps on MAR’s and addressing these with staff members, concerns that we found during this inspection had not been identified and addressed.

Feedback from people and relatives at the last inspection in August 2016 was noted to be negative around the issues of experiencing late calls. Staff told us and rotas confirmed that they were allocated very little or no travel time between calls. The provider was found to be in breach of Regulation 12 of the Health and Social Care Act 2008. At this inspection we found that very little had been done to improve this area of concern and that these issues were due to poor management of rotas. People, relatives and staff told us and rotas confirmed that they were allocated very little or no travel time between shifts which resulted in late visits and on some occasions missed visits.

Although some improvements had been made since the last inspection in August 2016 around risk assessments, the provider had failed in making improvements around the safe management of medicines and rota management to reduce the occurrence of lateness and missed visits. Lack of robust management oversight and governance meant that the provider had failed to identify the issues we found during this inspection. This meant that the provider continued to be in breach of Regulation 17 of the Health and Social Care Act 2008.

As part of the care planning process people’s individual risks were identified and assessed to ensure sufficient guidance was provided to staff to enable them to keep people safe and free from harm. Staff told us about safeguarding people from abuse and confirmed the actions that they would take if they were to observe any signs of potential abuse.

Robust recruitment processes were noted to be in place to ensure that staff recruited by the service were safe to work with vulnerable adults.

Care staff told us and records confirmed that they received training in a variety of topics which was refreshed on an annual basis. Staff were also required to complete competency assessments on the specific topic they had received training on. However, completed assessments that we looked at did not evidence that the assessments had been adequately checked by the training manager.

People and relatives told us that they had been involved in decisions that had been made about their care and support needs. This was documented appropriately within the persons care plan. Care staff demonstrated a basic understanding of the MCA and how their actions had an impact on the people they supported. Care staff told us that they never presumed people lacked capacity and always asked consent and offered choice to people in every aspect of care delivery.

Care plans were comprehensive and person centred. The service completed a section called ‘About me and my life history’. This detailed information about the person, where they grew up, previous occupation, information about family members as well as likes and dislikes in relation to the support that they received.

During the inspection we visited four people at their home. During this time we observed caring, positive and respectful relationships that staff had developed with the people that they supported.

The service carried out pre-service provision assessments which assessed whether the service could meet people’s needs as well as obtain details on how the person wished for their care to be delivered.

Staff understood people’s needs in relation to equality and diversity and that each person was different and possibly had different needs and requirements due to their religion, culture or sexual orientation.

People and relatives told us that they knew who to contact if they wanted to report any issues or raise a complaint. The service had a complaints policy and procedure in place which was made available to people and their relatives as soon as they began receiving care. However, where common themes were noted around lateness and poor communication, the service was unable to provide any evidence in relation to any action that had been taken to learn and improve the provision of care, in response to the concerns that had been raised.

Staff received regular supervision and an annual appraisal. However, we received mixed feedback from staff on the support that they received from the office and senior managers. The culture of the service did not promote openness and transparency.

At this inspection we found continued breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Westminster Homecare provides support and assistance for people who want to live at home and maintain their independence. They provide a wide range of personal care options and specialise in supporting people with dementia.

The service was last inspected on 04 February 2015 at their old location (Southbury House, 280-286 Southbury Road, Enfield, Middlesex, EN1-1TR). At our last inspection we did not identify any breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, we gave a recommendation around the service failing to not have completed a risk assessment for one person using a high-risk medicine. We recommended that the service review and implement national guidance, such as the National Patient Safety Agency anticoagulant and NICE guidance, with regards to the use and risk assessments for people prescribed anticoagulant medicines such as warfarin. At this inspection, we found that the service was still failing to complete risk assessments around high-risk medicines.

A registered manger was in place. A registered manger 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 law; as does the provider. The registered manager was present during our inspection.

Risk assessments were not always in place for identified risks. Risk assessments had not been completed for issues such as high risk medicines and known, significant health conditions. There were some risk assessments in place around manual handling. However, these did not always identify specific risks or provided care workers with enough information to mitigate those risks.

Medicines were not being managed safely. People told us that they received their medicines. However, medicine administration record often showed omissions in care workers signing for people’s medicines. The provider was unable to tell us if these omissions were where medicines had not been given or care workers had given medicines and forgotten to sign. There was a risk people may not have received their medicines. Medicines audits did not always identify these issues.

There were numerous late visits and people told us that care workers were regularly late. Staff were not always given travel time by the office in order to ensure staff were not late. This had not been identified or addressed by the provider.

Systems for auditing were in place and completed by the operations manager. However, audits failed to adequately identify issues that were found during the inspection.

The culture was not open and transparent. Whilst some staff said they felt supported, other staff felt their views were not listened to and that management was not accessible or supportive.

Some people received a continuity of care. The provider always tried to ensure that the same care workers looked after people. However, this did not always happen and some people and relatives said that they always had different carers and did not know who was going to be attending the care visit.

Staff had a good understanding of safeguarding and were aware of how to recognise and report abuse.

There was a system in place to monitor any missed visits. Missed visits were investigated and action was taken. The provider had an electronic monitoring system to monitor visits in Waltham Forest. There was no electronic monitoring system in Enfield and office staff completed monitoring visits and phone calls for people that were supported within the borough. Monitoring visits allowed the service to get from people and relatives.

People were encouraged to have input into their care and the service. The provider was beginning a service user forum where people would be encouraged to discuss issues and say what they did and did not like about the service they received. The first meeting was due to take place 19 September 2016.

People were involved in decisions about their care. Where people were assessed as not able to make certain decisions, best interests meetings and decisions on their behalf were made and recorded. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005.

People and relatives said that they were treated with dignity and respect. Staff were able to give examples of how they ensured that they promoted dignity. People were encouraged to be as independent as possible.

Staff received regular supervision and attended three monthly team meetings.

The service operated an on-call system for issues that arose out of hours. People said that they were able to contact someone in case of an emergency.

At this inspection we found breaches of Regulation 12, 16 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Care Quality Commission is considering the appropriate regulatory response to address some of the concerns we found during this inspection. We will publish what action we have taken at a later date. 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.