Archived: Carewatch (Norfolk)

Updated 13 November 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Prior to this inspection we reviewed the information we already held about the service. This included the previous inspection reports. We reviewed notifications which are important events the service is required to tell us about. We also viewed complaints and share your experience which are on the CQC website and enables people to fill in their experiences of the service anonymously or otherwise. We also received an action plan following the last inspection.

We reviewed the information the provider sent us in the Provider Information Return (PIR). This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

The inspection team consisted of two inspectors, an assistant inspector and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The experts by experience contacted people and relatives for feedback via the telephone over two days.

The first day of the inspection was 9 August 2018 and was announced.

We carried out some telephone calls on the 10 and 13 August to people using the service, relatives, health care professionals and staff. We visited some people using the service on the 14 August and again on the 16 August. We also carried out a second site visit on 16 August to gather more information. We then arranged with the registered manager to come back and provide some feedback when we had the opportunity to collate the information we had gathered. This took place on 7 September 2018.

As part of the inspection we visited six people in their own homes and spoke with a further 20 people on the telephone. We spoke with three care staff whilst doing our site visit, as well as four office senior staff. We spoke with a further seven staff on the telephone. We spoke with the registered manager who was the area manager but registered for this service to give it some stability. We also met the branch manager who is in the process of registering with the Care Quality Commission as the registered manager. We met the Quality Service Improvement Manager. We asked both for a break-down of their role and what they had been working on since our last visit. We spoke with four relatives and six health care professionals including the local authority who commission the service.

As part of the site visit we looked at records of staff recruitment and supervision for seven members of staff. We requested and received the staff training matrix. We looked at the assessments and care plans for nine people. We also looked at daily notes and medication administration records and the auditing of these. We looked at financial audits for two people. We looked at the service users’ guide, the complaints policy and records of complaints made with the action taken to investigate them. We looked at a small sample of records associated with people’s views about the quality of the service. We requested information be sent to us before and after the site visit.

Updated 13 November 2018

In April 2017 we inspected this service and found five continued breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014. The service was not employing enough staff to meet people's needs. Risks to people’s safety were not sufficiently assessed or managed and people’s care had not been planned or delivered to meet their individual preferences. There was poor oversight of complaints and the provider’s governance systems were ineffective. Following the inspection, we sent the provider a warning notice telling them that they must have adequate governance processes in place by 30 June 2017. The provider requested an extension to this deadline to 30 August 2017.

We inspected the service again on 13 and 15 December 2017. We identified the same breaches of regulation as the previous inspection. These were breaches for staffing levels, safe care and treatment, person centred planning, management of complaints and good governance. We rated the service as requires improvement overall, inadequate in well- led and placed the service in special measures. We do this when services have been rated as Inadequate in any key question over two consecutive comprehensive inspections. The Inadequate rating does not need to be in the same question at each of these inspections for us to place services 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, it 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.

This service is a domiciliary care agency. It provides personal care to people living in their own homes. At the time of the inspection it was providing care to 260 people. The service provides both 15-minute welfare checks or calls to support with medication administration only. Longer calls were scheduled according to people’s assessed needs. The service also supported people over a limited amount of time to prevent hospital admission or readmission to hospital.

There was a registered manager at 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.

During the first day of our inspection on 9 August 2018 we identified four continued breaches of regulation. We have rated this service as requires improvement in four key questions and inadequate in well- led. This means the service will stay in special measures.

Improvements had been made but were not firmly embedded across the whole service which meant people received different outcomes of care. Some recent changes within the service compromised the continuity of care. For example, office staff, including coordinators. The registered manager said to make improvements to the service some of the staff employed had needed to leave to develop a new and more positive care culture. However, changes in the staff team meant that not all the care visits were planned sufficiently ahead or around the needs and wishes of people using the service. Staff said they did not always have regular care visits or adequate travel time. This meant they did not always arrive on time for the care visit, or stay the correct amount of time. This evidence supported a repeated breach of regulation 18: staffing.

Recruitment of new staff was not always carried out in line with the organisation’s policies and procedures which meant people were not fully protected against the potential employment of unsuitable staff.

There were processes in place to help ensure people received their medicines as intended but audits were not always completed in a timely way and we found improvements were required in recording. This supports a breach of regulation 12: Safe care and treatment.

Risk assessments regarding people’s care were documented. However, the individuals’ care plans and records were not always adequate in informing actions staff should take to keep the person safe.

Infection control measures were in place but not all staff were adhering to them placing people at an increased risk of cross- infection. We found through discussion with people that not all staff were wearing personal, protective clothing.

Safeguarding people from abuse was effective because the service provided staff with adequate training and had systems in place for dealing with any allegation of abuse. The agency worked closely with the local authority to ensure all allegations were reviewed.

The service had systems in place to review all accidents and incidents within the service. This enabled the service to evaluate what had gone well or what they could learn to help ensure that the risk was reduced in the future.

The service kept up to date with changes to legislation and best practice but this was not always communicated to care staff. Several staff said they had not had recent face to face supervision, or direct observation of their practice which they felt was due to recent changes to the management team. We were unable to see from the information provided that all supervision was up to date in line with the organisations policy. This meant some staff were working in line with their own values and not necessarily the values of the company. Communication was disjointed across the different teams. This supported a breach of Regulation 18: staffing.

Staff received regular training and the quality of training provided through induction was said to be good. However, some staff said they did not have the time to attend specific training around the needs of people using the service.

People mostly had their health care needs met and this was reflected by what staff told us. However, we were concerned that staff were rushing in and out of people’s houses which increased the risk of them missing something important or not noticing a change in the person’s needs. We considered this in line with poor record keeping which could increase the risk of the person receiving poor care.

Staff had received training in the Mental Capacity Act 2005 (MCA.) The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. Care plans recorded people consent, (or their legal representatives consent) to care and treatment.

We saw examples of where people’s choice was diminished in relation to their choice of carer and their preferred timing of care call. People also stated they were rushed or their call was cut short which affected the person’s experience of their care.

People were consulted about their care plan and this was reviewed although people felt contact with the office was not always regular. Care plans were not sufficiently robust or person centred. Records were not always up to date, or legible.

People knew how to complain and staff understood the process and how they should support people if they had concerns. The paper records reviewed showed the outcome of complaints received were not always fully documented to show if it had been upheld or how it had been resolved. However, complaints were also logged electronically and could not be closed until all necessary actions had been taken. This was not viewed as part of the inspection and would have provided a fuller audit trail.

The service was not sufficiently well managed. There were insufficient resources to ensure people always received good outcomes of care and received support around their needs. Quality audits did not always demonstrate how the service was identifying and making necessary improvements in a timely way.

The service remains non -compliant in a number of areas and will therefore remain in special measures due to its history until we are confident that the service can make and sustain the necessary improvements. This supported a breach of regulation 17: Good Governance.