Archived: Mears Care Torbay and Devon

On 17 September 2018 the service took over the care visits of an agency that had closed down, this equated to 156 people having care visits. Prior to the transfer, Mears Care Ltd worked with Devon County Council and the provider of the agency that was closing, on a transition plan to ensure safe transfer.

At the time of the inspection and again following the inspection, we asked senior management how many people they now supported with personal care and how many care visits they carried out a week, including those people from the new contract. We did not receive this information.

There was no registered manager in post; however, the operations manager had made an application to register with us but this was withdrawn on 13 September 2018.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.

The service had been inspected on three previous occasions. In October 2016, the service was rated ‘Inadequate’ in all five key questions. We identified eight breaches of the Health and Social Care Act 2008 and associated regulations. The Care Quality Commission (CQC) took enforcement action against Mears Care Limited and imposed a condition on the provider's registration.

We inspected this service again in June 2017 when we found improvements had been made. No breaches of the Health and Social Care Act 2008 Regulations were identified, and the service was removed from special measures. During this inspection we rated the service ‘Requires Improvement’ overall as improvements were still needed to protect the rights of people who lacked the mental capacity to consent to care and treatment as well as to the service's quality monitoring systems.

The service was last inspected between October and December 2017 in response to concerns raised that the service was not able to provide care visits to people as planned. The service was rated as ‘Requires Improvement’. We identified one breach of the Health and Social Care Regulations (Regulated Activities) 2014 and made one recommendation for improvement.

On Monday 24 September 2018 we received information of concern from two relatives and one member of staff that a significant number of people were not receiving care visits as planned. We were also made aware that the local authority, Devon County Council, had been working with the service in crisis management over the weekend, as there were multiple missed care visits. We undertook this focused inspection on 2 and 4 October 2018 to look into the concerns raised.

At this inspection, we found serious shortfalls in the management of risk, insufficient staffing levels and leadership and governance. The overall rating for this service has deteriorated from 'Requires Improvement' to 'Inadequate' and the service is therefore placed 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.

The leadership and management of the service was inadequate. We looked at how the provider had managed the transfer arrangements of the care packages between themselves and the care provider who had ceased business. We found governance systems to ensure smooth transfer between providers, safety and continuity of care and consistency of staff had not been effective in ensuring people received safe care that met their needs.

We found there was a lack of management oversight and the systems and processes in place had not ensured that people received their care visits as planned and this had placed some people at risk of avoidable harm. We found the service’s business continuity plan, although instigated, had been ineffective in managing/mitigating risks associated with staffing levels. Concerns from senior staff about insufficient staffing numbers prior to the transfer of care packages, had not been escalated to higher management level at Mears Care Ltd or to the local authority.

People were placed at risk because the provider did not ensure there were enough staff available at all times to deliver planned care. We found the systems and processes followed during the transfer of care packages, were not robust or managed effectively. This meant systems had not identified that a significant number of staff were not transferring to Mears Care Ltd and the provider did not have a robust contingency plan in place. This resulted in 91 missed visits between 17 and 23 September 2018, which placed people at risk of avoidable harm.

People were at risk because the provider had not made every reasonable effort to gather information about potential employees transferring from the other care provider to ensure they were of good character and had the necessary employment checks in place such as police checks.

People did not always receive safe care and support. Some people were left for long periods of time without their basic care needs being met. For example, some people were left in wet beds or soiled pads because they could not get out of bed or to the toilet without help. One person told us that they were in a wet bed from 7am until the carer visited at 2.30pm. They told us they had no breakfast or medicines as they relied on carers to get them out of bed. They told us, “I felt helpless, very unsafe, distressed and vulnerable.”

Other people were at risk of not receiving sufficient nutrition and hydration. Some people relied on care staff to prepare their meals and drinks, where care visits were missed people went without food and drink as they were unable to prepare this for themselves.

People were not always protected from the risk of harm. Where people had been identified as needing two staff to support them safely, this was not always being provided due to the reduced staffing levels. This resulted in care that was unsafe, placed the person and staff at risk, and did not meet the person’s assessed needs. One person told us they felt unsafe.

People did not always receive their medicines as prescribed. Where visits had been missed or were late, people had not received their medicines which put them at risk of harm. For example, people taking medicines to manage their diabetes or heart conditions. People taking medicines for pain control were subjected to avoidable pain and discomfort due to missed or late visits.

Arrangements in place to review people’s care needs prior to the transfer, had failed to identify that 12 people had not had their needs assessed and did not have a care plan in place. This meant staff had not been provided with sufficient information to meet these people’s needs.

People and staff were not always given the information they needed and there was a lack of communication. People and relatives told us they were not kept informed about any changes to their care. We heard of many examples of people phoning the office and not receiving a response. This lack of communication had left people angry, frustrated and extremely anxious as they did not know from one day to the next who was coming or if anyone would turn up. One person said, “No one has called to say sorry or explain why this happened.”

Staff we spoke with were passionate about their work and knew changes needed to be made but were extremely upset and frustrated by the organisation and how the transfer had been managed. Staff told us they did not feel listened to and when staff had raised concerns these were not taken seriously, and action was not taken. A relative told us, “Staff have been marvellous, but they have too much work to do. One young carer, who was very apologetic for being so late, broke down in tears.”

This announced comprehensive inspection took place on 31 October 2017, 9, 14, 17 and 23 November 2017 and 4 December 2017. The inspection was undertaken in response to concerns raised with us by South Devon and Torbay NHS Foundation Trust (The Trust) about the service not being able to provide care visits to people as planned. The Trust also provided us with feedback from a Healthwatch consultation with people using the service, some of whom were dissatisfied with the care and support they received. Healthwatch is an independent consumer champion for health and social care.

The service has been inspected on two previous occasions. In October 2016, the service was rated inadequate in all five key questions. We identified eight breaches of the Health and Social Care Act 2008 and associated regulations. The Care Quality Commission (CQC) took enforcement action against Mears Care Limited and imposed a condition on the provider's registration. This required the provider to send a fortnightly progress report on the areas of greatest concern and risk. The service was put in 'special measures'.

We inspected this service again in June 2017 when we found improvements had been made. No breaches of the Health and Social Care Act 2008 Regulations were identified and the service was removed from special measures. However, at our previous inspection in June 2017 the Mears Care Limited service at Torquay relocated to Mears Care Torbay and Devon. The Torquay service had an ongoing breach of regulation in relation to complying with the Mental Capacity Act 2005 (MCA) to protect the rights of people who lacked mental capacity. We therefore rated the service Requires Improvement overall as improvements were still needed to protect the rights of people who lacked the mental capacity to consent to care and treatment as well as to the service’s quality monitoring systems. We rated three key questions, (is the service safe, caring and responsive?) as Good.

At this inspection we found improvements had been made. However, the overall rating of the service remains Requires Improvement. This is the second consecutive inspection where the service has been rated Requires Improvement.

Since the inspection in October 2016, the service has continued to provide CQC with the required progress reports.

The service did not have a registered manager. The registered manager who was in post at the time of the previous inspection left the service in August 2017. The providers had appointed a new manager who told us it was their intention to apply to register with the Care Quality Commission. 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.

Prior to this inspection, we were informed by the Trust that the service had been unable to provide care to a number of people due to insufficient numbers of staff available over the October 2017 half-term week. Although the majority of these care visits were undertaken by the service, it was necessary for the Trust to provide staff to undertake 12 of these visits. The shortfall in the availability of staff to provide care visits was as a result of more staff taking annual leave than normally agreed and a number of staff reporting sick. In addition, there were other times when people’s visits were late or missed.

Some people told us they had experienced late visits, while other people said staff arrived on time. Some people also reported having changes made to their care visit rota and receiving care from staff they did not know. Four relatives told us their relative was anxious when receiving care from unfamiliar staff. The review, undertaken by the Trust in response to the service failing to provide sufficient staff to undertake care visits, also indicated people were experiencing frequent changes to their planned rota of visits.

Staff said they had changes made to their rotas, sometimes at short notice and some staff said they were not provided with sufficient travel time between visits. Staff said they felt rushed but tried not to leave visits early but this meant they were frequently running late. People told us they felt the staff were rushed but that they did not feel rushed when receiving care and support.

The manager and quality assurance team told us changes have been made to the way in which staff were recruited, how annual leave was agreed and to how the rotas were planned to improve the consistency of care staff. This had resulted in an improvement in the number of late and missed visits. Data analysis from the service’s computerised system was used to identify the number of visits completed on time, the number of late and missed visits and individual staff visit attendance records.

Risks to people’s health, safety and welfare were assessed and staff were provided with the training they required to care for people safely. Medicines were managed well. People’s care plans had recently been reviewed and these provided guidance for staff about people’s care needs and how they should provide support. People’s consent to receive care and support had been obtained, and where people had been unable to consent to their care, best interest decisions had been made to provide support. The service worked closely with health care professionals such as GP and community nurses to ensure people’s health care needs were being met.

People told us they felt safe using the service. People described the care staff as “superb”, “lovely” and “excellent”. Staff were recruited safely and had received training in how to recognise and report abuse. Staff confirmed they were confident any allegations would be taken seriously and investigated to help ensure people were protected.

People were supported to express their views and the service sought their feedback about the quality of the care and support they received. Where concerns were raised the service developed an improvement plan to resolve issues. Staff had been provided with training to improve the way in which complaints received by the office staff were handled. Where people had been dissatisfied with the way the service responded to their concerns, the manager and quality assurance team met with them and with the local authority to try to resolve the matter.

There was a management structure in the service which provided clear lines of responsibility and accountability. One of the service’s values was to put the “customer at the heart of everything we do”. The director, manager and all the staff we spoke with told us this was something the service and they as individuals strived to do. All felt there had been improvements to the service since the previous inspection and following the merger of the two offices. Regular management and staff meetings were held to ensure each was aware of the service’s performance and to monitor the effectiveness of the changes put in place to improve people’s experiences.

We identified one breach of the Health and Social Care Regulations (Regulated Activities) 2014 and made one recommendation for improvement.

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

Concerns at that time related to staffing levels, skills and knowledge; staff not receiving the support they needed; the service not always being caring; late and missed visits, resulting in risks to people's welfare and safety; lack of care planning and poor systems for listening and responding to people’s concerns. The service was not well led and governance systems were not effective.

The provider sent an improvement plan outlining the immediate steps being taken to protect people and improve the service. They transferred most people’s care packages to other care providers. Representatives of CQC held a meeting with the provider on 22 November 2016 to discuss their improvement plan. By January 2017, the people cared for by Mears Care Kingsteignton had reduced from 143 people to one person. The provider has continued to send monthly progress reports to CQC which showed continuing improvements at the service.

Following the inspection, a whole service multiagency safeguarding process was convened to protect people's safety and well-being. Devon County Council suspended contracting new packages of care with the agency. Health and social care professionals visited the service as part of a safeguarding investigation and in a protection role. The provider worked with the local authority quality and improvement team to improve their quality monitoring arrangements. In January 2017 feedback from multiagency meetings confirmed care had improved and risks had significantly reduced; the whole service safeguarding process was closed.

Devon County Council commission Mears Care Torbay and Devon under the ‘The living well at home’ scheme to identify personal care services for people in Devon who need them. Most of those services are sub contracted to other agencies and the service is no longer offered to any new privately funded people. Mears Care Torbay and Devon has a small response team that provides personal care for small numbers of people. This team provides care for people for short periods, whilst waiting for other services to set up people’s long term packages of care. At the time of the inspection the agency was providing care and support to 10 people in Tavistock, Exeter and East Devon.

The service has a registered manager who was registered on 12 June 2017. 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 this inspection we found people felt safe using the service and said it was reliable, and there were no missed visits. People were supported by enough staff so they could receive care at a time and pace convenient for them. Staff knew about the signs of abuse and worked closely with health and social care professionals to implement measures to protect people.

Staff had the skills and training needed to carry out their role although further training needs were identified which had yet to be addressed. People confirmed staff sought their consent before providing any care. Staff demonstrated a good understanding of the Mental Capacity Act (MCA) (2005) and how this applied to their practice. The service had updated its MCA policies and procedures, although relevant staff training had not yet taken place.

Risk assessments identified the steps staff needed to take to promote people’s safety and welfare. People received their medicines on time and in a safe way. The agency had robust recruitment procedures in place for recruiting new staff.

People, relatives and professional feedback consistently showed the service was person centred and responsive to people’s individual needs and preferences. This enabled people to live as full a life as possible. Care staff were motivated and spoke with kindness and compassion about the people they supported.

People's care plans were detailed and comprehensive and described positive ways in which staff could support them. Care records had personalised detailed information about each person, their needs and preferences and what mattered to them. People knew how to raise any concerns or complaints and felt confident to do so and positive action was taken in response to make improvements.

People, relatives and staff said the agency was well run and improvements had been made in quality monitoring. The culture of the service was open, staff acknowledged past difficulties and were focused on improvement. Care and office staff worked well together as a team, and senior staff were continuing to develop the staff team and promoted high standards of care. The provider had a range of quality monitoring systems which included regular review meetings, audits, feedback from people, relatives and staff and spot checks. Spot checks are checks of care carried out in people’s homes by a senior member of staff. They include looking at staff care practices, at communication skills, knowledge, privacy and dignity and attitudes. The provider made continuous improvements in response to the findings of audits, complaints, accidents and incidents.

At the inspection senior staff told us about imminent plans to relocate the Mears Care Torbay office to Kingsteignton. CQC have since received an application to cancel the registration of Mears Care Torbay. Previously, Mears Care Torbay was also rated Inadequate overall with nine breaches following an inspection in September and October 2016. CQC imposed a similar condition on the provider’s registration and placed the service in special measures. A follow up inspection of Mears Care Torbay was carried out during June and July 2017 and found significant improvements had been made. However, two ongoing breaches of regulations relating to consent and quality monitoring were identified and the service was rated requires improvement overall and in each domain. Since the inspections, the Mears Care Torbay service has relocated, (now renamed Mears Care Torbay and Devon). This represents an increased level of risk at this branch. The provider will need to monitor closely the impact of these changes on the quality of the service. We have made a recommendation about this.

During this inspection the service demonstrated that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, the service is now out of special measures and is rated as ‘Requires improvement’.

There was a registered manager in post however the provider notified us they were off work for at least 28 days. There was a branch manager in post who was managing the 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.

This location was registered in July 2016 and has been operating a service since that date. The provider had transferred the care delivery for South Devon from the location in Torquay to this location. They had taken on additional work for the Exeter and East Devon area.

During August and September 2016, we received concerns from people, staff, local authority safeguarding, and the ambulance service in relation to the quality of care being provided. In response to those concerns we undertook this unannounced inspection which commenced on 3 October and ended on 13 October 2016.

We found significant concerns which meant some people did not always receive their care as planned and were placed at risk of harm.

The service did not employ enough staff to meet people’s needs. This meant some people had not always received their planned visits or visits were late. This resulted in risks to people’s welfare and safety. For example, some people missed their medicines and missed their meals. People who needed two care staff at each visit had one staff member arrive. This meant care could not be carried out as required, or safely; relatives/representatives were supporting the care staff to deliver care. This placed people and staff at risk of injury or harm.

Staff providing care and support did not always have the skills and knowledge they required to care for people. When updates in staff training were required these had not been provided. Staff had not received regular supervision and appraisals. The majority of staff had not had any recent observations of their work. This meant the provider could not be assured staff had the skills and knowledge they needed to meet people’s needs safely and appropriately.

Some people did not receive support in a caring way, particularly when care was delivered by staff they didn’t know well. People told us they were unhappy with the lack of continuity of care staff. This had caused distress, especially for people living with dementia who needed to see familiar faces. People said they had been unable to speak with managers and did not receive a return call when they requested it. Some people told us they were ‘fobbed off’ and found out that information given to them was untrue. Other people found staff to be caring and had built good relationships. People told us they were happy when they received care from staff they knew well.

Care plans had not been in place for some people before their package of care started. People's individual plans of care did not always contain enough information for staff to deliver care safely or in a person centred way. Where risks were identified, these were not fully assessed or sufficient action was not taken to ensure people received care in a safe way. People received inconsistent levels of care and support that was not provided according to their individual preferences. People told us care staff did not always stay for the allocated time and their care was sometimes rushed.

Information management systems were not used to support the delivery of a safe service. Reports about visits, time critical visits, visits where two care staff were needed could not be accessed by staff who had responsibility to plan and monitor visits. This meant the provider was unable to ensure that everyone was receiving a visit, or identify and resolve missed or late calls to people.

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 provider.

There had been a lack of leadership, governance and managerial oversight of the service. The provider did not have an effective system in place to regularly assess and monitor the quality of the service people received. The local authority had suspended new packages of care. The new branch manager told us they wanted to improve the service. We saw evidence the Nominated Individual was taking action to make the required improvements. By the end of our inspection, the following actions had been taken; Senior managers had been brought into the location to support the branch manager and staff. Reports were now available and were being used to monitor and manage risk, ensuring people received their care as planned. The local authority who commissions the service is working with the provider.

At this inspection we found the service to be in breach of eight regulations of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this 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.