Total Health Support and Training Services Limited

Total Health Support and Training Services Limited is a domiciliary care agency. It provides personal care to people living in their own homes in the community. It provides a service to older and younger people, some of whom may be living with dementia. This service also provides care and support to younger adults who have learning disabilities or autistic spectrum disorder living in 'supported living' settings. This is so that they can live in their own homes as independently as possible. In supported living, people's care and housing are provided under separate contractual agreements. The Care Quality Commission (CQC) does not regulate premises used for supported living; this inspection only looked at people's personal care and support. At the time of our inspection there were 73 people receiving a service. Of those 73 people, 13 were living in supported living settings in five different houses.

Not everyone who used 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’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

Systems in place to protect people from the risk of harm or abuse were not always effective. Medicines were not managed safely.

Staff training was not up to date. Records indicated a number of staff had not completed training. People’s care plans did not always contain sufficiently detailed information to support staff to protect people from identified risks.

There were sufficient numbers of staff to provide consistent care to people. Staff reflected on practice when incidents occurred to prevent recurrences. People were protected from the risk of acquiring an infection.

People received individualised support which promoted their independence and upheld their human rights.

Staff worked within the principles of the Mental Capacity Act and demonstrated the appropriate legal requirements had been met where people had been deprived of their liberty.

People were always 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.

Recruitment processes and were in place to support consistent teams of staff to deliver person-centred care and support. There was evidence of effective partnership working with external professionals to promote people’s safety.

Right Care:

Most people received care which met their individual needs and preferences. People, their legally appointed representatives and relevant professionals were involved in developing their care plans which were regularly reviewed.

People’s care and support needs were assessed using a structured process. People were supported to maintain a healthy diet. Staff worked with professionals from health and social care to help meet people’s needs.

People experienced continuity of care from a core team of staff. Staff demonstrated compassion, sensitivity and respect in their interactions with people who they knew well.

Right Culture:

Governance and leadership at the service were not adequate. Systems and processes were not used effectively to monitor quality and improve safety in the service. Audits of people’s medicines records were not always effective in identifying and analysing shortfalls to improve safety. Audits were not used effectively to monitor themes and trends to drive service improvements.

The registered manager sought feedback from people and staff about how the service was run. Staff worked with professionals from different disciplines to promote people’s health and wellbeing needs.

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 good (report published 23 April 2018)

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of skin damage, moving and handling and mental capacity. This inspection examined those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this report.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Total Health Care and Support Services Limited on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, staff training, and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

At the last inspection in February 2017 we found the service was not meeting all fundamental standards as required. Staff were not being provided with appropriate training, competency assessment and performance appraisals and the provider had not established an effective system that ensured their compliance with the fundamental standards. Following that inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions safe, effective and well-led to at least good. At this inspection we found the provider had taken the action they said they would and had improved the service to an overall rating of good, with a rating of good in all key questions.

Total Health Support and Training Services Limited is a domiciliary care agency. It provides personal care to people living in their own homes in the community. It provides a service to older and younger people, some of who may be living with dementia. This service also provides care and support to younger adults who have learning disabilities or autistic spectrum disorder living in ‘supported living’ settings. This is so that they can live in their own homes as independently as possible. In supported living, people’s care and housing are provided under separate contractual agreements. The Care Quality Commission (CQC) does not regulate premises used for supported living; this inspection only looked at people’s personal care and support. At the time of our inspection there were 82 people receiving a service. Of those 82 people, 14 were living in supported living settings in five different houses.

The provider is also registered to provide nursing care to people in their own homes. No nursing care was being provided at the time of this inspection.

The service had a registered manager as required. A registered manager is a person who has registered with the CQC 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 registered manager was present and assisted us during the inspection.

People were protected from the risks of abuse. Risks were identified and managed effectively to protect people from avoidable harm. Recruitment processes were in place to make sure, as far as possible, that people were protected from staff being employed who were not suitable.

People were treated with care and kindness. They were consulted about their support and could change how things were done if they wanted to. People were treated with respect and their dignity was upheld. This was confirmed by people and the relatives who gave us their views. People were encouraged and supported to maintain and increase their independence.

People received care and support that was personalised to meet their individual needs. In the supported living houses, people were supported to access local events to enhance their social activities. This meant people had access to activities that took into account their individual interests and links with different communities.

People received effective care and support from staff who knew them well and were well trained. They told us staff had the training and skills they needed when providing their care and support. People received effective health care and support. Medicines were stored and handled correctly and safely.

People knew how to complain and knew the process to follow if they had concerns. People's rights to make their own decisions were protected. 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.

Where people were potentially being deprived of their liberty, the service had made the relevant commissioning authorities aware. This was so that commissioners could make applications to the Court of Protection for the appropriate authorisations.

People's right to confidentiality was protected and they received support that was individualised to their personal preferences and needs. People's diversity needs were identified and incorporated into their care plans where applicable.

People benefitted from a service which had an open and inclusive culture and encouraged suggestions and ideas for improvement from people who use the service, their relatives and staff. Staff were happy working for the service and people benefitted from staff who felt well managed and supported.

Total Health Support and Training Services Limited is a domiciliary care service providing personal care to people in their own homes. At the time of our inspection there were 62 people receiving a service. Of those 62 people, 10 were living in supported living accommodation. The provider is also registered to provide nursing care to people in their own homes. No nursing care was being provided at the time of this inspection.

The service had a registered manager as required. A registered manager is a person who has registered with the CQC 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 registered manager was present and assisted us during the inspection.

Staff received some training to enable them to do their jobs. However, initial induction training was not always completed in line with the provider's policy and staff were lone working before completing the training deemed mandatory by the provider. Updated training for staff was not always provided at the intervals the provider had determined. Training in the handling of medicines was not up to date for all staff and no staff had received medicines administration handling competency assessments since 2014.

People, their relatives and staff felt the service was managed well. Quality assurance systems were in place to monitor the quality of the care and support being delivered. However, the management auditing systems in place were not always effective in ensuring the service was compliant with current legislation or in line with the provider's policies. This related especially, although not exclusively, to providing staff with appropriate training and ensuring they were competent to do their jobs. Although there was no evidence that this had had a negative impact on people using the service, people were placed at risk of not being supported appropriately because staff were not appropriately trained.

Safe recruitment practices were followed before new staff were employed to work with people. Although some gaps were found in employment histories, these were quickly rectified and a new checking procedure put in place. Other required checks were made to ensure staff were of good character and suitable for their role.

People received support that was individualised to their specific needs. Their needs were monitored and care plans reviewed regularly or as changes occurred. People's rights to make their own decisions, where possible, were protected and promoted by staff.

In relation to the way their care packages were delivered, 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.

People were treated with respect and their privacy and dignity was promoted. Staff were caring and responsive to the needs of the people they supported. Staff sought people's consent before working with them and supported their independence.

People told us they received the care and support they needed, when they needed it. People's personal care needs were assessed and measures put in place to ensure those needs were met.

People were protected from abuse and staff had a good understanding of action they should take if any concerns were raised or suspected. Staff were available in enough numbers to meet the needs and wishes of the people they supported.

We found breaches of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff were not provided with appropriate training, competency assessment and performance appraisals as was necessary for them to carry out the duties they were employed to perform. The provider had not established an effective system that ensured their compliance with the fundamental standards. The fundamental standards are regulations 8 to 20A 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.