Archived: Wiltshire Care at Home Service

This visit to the service took place on 1 December 2015 and phone calls were made to people who use the service on 30 November and 2 December 2015. This was an announced inspection which meant the provider knew two days before we would be visiting. This was because the location provides a home care service. We wanted to make sure the manager would be available to support our inspection, or someone who could act on their behalf.

The service did not have 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 and associated Regulations about how the service is run. The service has a condition of their registration that a registered manager must be in post. Since the last registered manager left in September 2015, the service has been managed by one of the locality managers. The manager told us she had submitted an application to CQC to be the registered manager shortly before the inspection. Records confirmed this application had been received by CQC and was being assessed.

The systems in place to manage risks related to the administration of medicines were not completed consistently. Information on how to provide support to people with their medicines was not always available. The missing and contradictory information increased the risk that staff would not provide support that people needed with their medicines or provide support to people that was unsafe.

The provider’s systems for gaining and recording consent for care and treatment were not always followed by staff. This meant it was not possible to say whether some people consented to the care and treatment they were receiving, or if they did not have capacity to consent to their care that requirements of the Mental Capacity Act had been followed.

People who use the service and their relatives were positive about the care they received and praised the quality of the staff. Comments from people included, “They are very good, very caring”, “Yes, they are caring. They are not rude or clumsy, they’re very nice” and “They are very kind to me”. A relative also expressed satisfaction with the caring way staff supported their family member, commenting, “They are definitely kind and caring. They talk to (my relative) and tell him what they are going to do”.

People told us they felt safe when receiving care and were involved in developing and reviewing their care plans. Systems were in place to protect people from abuse and harm and staff knew how to use them. People said the care workers generally arrived on time, and they would receive a call to inform them if there were any problems.

Staff understood the needs of the people they were providing care for. Staff were appropriately trained and skilled. They received a thorough induction when they started working for the service and demonstrated a good understanding of their role and responsibilities. Staff had completed training to ensure the care and support provided to people was safe and effective to meet their needs. However, the training records were not all up to date, which made it difficult for the management team to keep a track of training staff had completed and to plan future training events.

The service was responsive to people’s needs and wishes. People had opportunities to provide feedback about their care and there was a complaints procedure. Although people said they would raise any concerns with staff, they were not all aware of the formal complaints procedure for Leonard Cheshire. The manager said they would look at the information they were sending out to review whether it could be provided in a clearer way.

The provider regularly assessed and monitored the quality of the service provided. Feedback from people and their relatives was encouraged and was used to make improvements to the service.

We found breaches 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 this report.

Two inspectors visited the service and answered our five questions, Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well-led?

Is the service safe?

The service was delivering care as specified in a contract designed by the local authority, which changed the usual care given by an agency. Care was contracted to meet the outcomes they had identified for people. This meant that visits were not necessarily time or duration specific. This type of contract was complicated to monitor. The agency had developed a method of ensuring that care packages were monitored more effectively. A very high percentage of people who responded to the questionnaires felt safe with their carers and nobody reported discrimination of any kind.

Care plans instructed staff how to meet people's needs in a way which minimised risk for the individual. The agency contract with the local authority required the agency to accept all referrals and they may be instructed to provide care within four hours of a referral. If the service did not have the necessary expertise or resources available the manager worked with the social services and did not offer care until they could do so safely.

Staff were monitored and supervised by senior staff members. The service had developed ways of improving staff support.

Missed calls were investigated as safeguarding concerns. There had been seven reports of missed calls since 1 May. The service provided approximately 7,000 calls per week.

Is the service effective?

Overall people who used the service and relatives/friends seemed satisfied with the service being provided by Wiltshire Care at Home Service. Generally, people who used the service that responded felt that they get the overall care and support that they need from the care workers.

The service had ensured that 81% of people were looked after regularly by the same care staff. The manager told us that the small percentage who did not have regular care staff were mainly people who had short term care packages or those affected by staff sickness or leave. People who responded to the questionnaire told us that care workers generally stay for the agreed length of time, and arrive mostly on time. People felt that their carers always or mostly treated them with respect.

Overall, people who used the service rated the care they received from the agency as 'good' or excellent'. Only two responders rated their care as 'satisfactory' and nobody who used the service rated their care as 'poor'.

Any 'sub-contracted' staff (from other agencies) were subject to the same policies, procedures and conditions as the agency's own staff.

Is the service caring?

People told us that their carers always or mostly treated them with respect. People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The service had installed a new telephone system in response to concerns about telephones not being answered and people and staff being unable to communicate with office staff.

The questionnaires produced four negative comments such as the timing of calls or there not being enough time for carers to do what they needed to.

The manager told us she was aware that there was further work to do to ensure high standards of care. We saw plans for further development of the service.

Is the service well-led?

The agency had developed the management structure so that it was able to support a large staff team more effectively. Staff told us that they had received formal supervisions and communication between them and the office had improved. They told us that the manager was very approachable.

One inspector visited the service and answered our five questions, Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them, other professionals and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was delivering care as specified in a contract designed by the local authority, which changed the usual care given by an agency. Care was contracted to meet the outcomes they had identified for people. This meant that visits were not necessarily time or duration specific. This type of contract was new and complicated to monitor and there were risks because the agency had not fully developed a method of ensuring that care packages were effectively monitored.

Care plans instructed staff how to meet people's needs in a way which minimised risk for the individual. However, the agency contract with the local authority required the agency to accept all referrals and they may be instructed to provide care within four hours of a referral. If the service did not have the necessary expertise or resources immediately available there could be a risk to the quality or effectiveness of the care.

Medication was, generally, administered safely and at the correct times to ensure people's health and well-being. However, there had been incidents of medication not being given at the appropriate times. These were being investigated as safeguarding concerns.

Staff were not effectively monitored or supervised. This could cause a risk to people who used the service who could be cared for by ineffective staff. The service was developing ways of improving staff support but this work was not fully completed.

The service had several outstanding safeguarding investigations underway which were mainly in response to complaints about 'missed calls'. Missed calls could mean that people who used the service were at risk because care staff did not arrive when they should. The service had developed and was developing ways of improving this but this work was not fully completed.

Systems were in place to make sure that the manager and staff continually monitored the quality of care offered to people. Health and safety was taken seriously by the service and all the appropriate policies and procedures were in place. The quality assurance systems had identified the concerns and risks we noted at the inspection. There were plans in place and being developed to address the issues.

Is the service effective?

People told us that it was: 'a very good service' and: 'we have been very pleased with the service'. Two of the seven people we spoke with, on this occasion told us that the care was less good at weekends. They told us that they had a large number of different care workers and sometimes calls were missed or the care was not as good as usual. Overall people told us that they were very happy with their usual care workers but were less confident when they were being supported by staff they didn't know.

The service made sure staff were trained to give people the care that they needed. However, the practice of 'sub-contracting' to other agencies meant that it was difficult to guarantee the effectiveness of staff who were not recruited or trained by the agency.

Is the service caring?

People told us: 'I'm quite happy with carers, I don't want anyone to take them away'. They told us they felt respected and one said staff: 'talk very nicely to me, we think of each other as friends'.

People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The service had a variety of ways of listening to people who used the service. People told us that they were happy to call the office, if they needed to but their ''usual carer'' generally sorted things out for them.

Staff told us that they encouraged people to make formal complaints if the care wasn't as it should be. They said that they would make complaints on their behalf, if necessary.

The service is making major changes in response to recent Care Quality Commission inspections.

Is the service well-led?

The management structure of the service was not able to support a large staff team. Staff told us that they did not receive formal supervisions and were not always able to contact senior staff for support.

The manager of the service had recognised all the issues and was, with the support of senior management, developing methods of improving the service.

The service had a quality assurance system, records seen by us showed that the service had identified shortfalls and risks within the service. Systems to meet with Care Quality Commission requirements were being developed and identified issues were being addressed.

People and their relative's views on the service varied. Factors that influenced their opinions were: having a regular carer and the carer understanding their care requirements. One person told us "the regular carer I see is wonderful." However, several people explained how not having their regular carer caused them concern. One person said "it's scary having someone who I don't know well. I have had my main carer for years. She knows me and recognises if I am not well. It takes a long time to get to know a new person, especially if they are new to care." We saw from provider data the recommended percentage of people receiving a regular carer did not meet the provider's recommendations.

People told us they were involved in their support plans and their permission was always sought before any care commenced. The plans we looked at were up to date. However provider information demonstrated care reviews did not take place within recommended time frames.

Staff we spoke with told us there were times when they did not feel supported. We saw from provider records, staff had not had supervision sessions, annual appraisals and team meetings in line with the provider's recommendations.

The provider had systems to assess and monitor the quality of the services provided.

Staff gave us examples of how they supported people's care needs. One care worker described how they administered first aid when a person had a fracture. Another care worker explained the importance of providing continuity and knowing the person to ensure people received the care they needed.

People we spoke with told us their privacy and dignity was respected. " One person said you could feel vulnerable but they (the staff) respect my privacy and dignity." People told us they were involved in their care planning and were encouraged to be as independent as possible.

Staff were knowledgeable about safeguarding vulnerable adults and recognising and reporting abuse.

Overall there were enough staff to care for people.

Staff were appropriately supported during the induction period. We saw from training records staff attended regular training updates to update their knowledge and skills on areas such as moving and handling, medicines management and safeguarding of vulnerable adults.

The provider had a system in place to monitor the quality of the service provided.