Voyage (DCA) Wiltshire

Voyage (DCA) Wiltshire is registered to deliver personal care to people in their own homes or in a shared house arrangement. 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. At the time of this inspection the service was supporting 42 people under the regulated activity and 61 people in total were using this service.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 providing support to people with a learning disability and/or autistic people.

Not all the key questions were inspected at this time, but the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture in relation to the Safe and Well-led key questions.

Right support:

• People had risk assessments in their care plans, these detailed individual risks to people in a thorough and person-centred way.

• The service worked with external professionals to meet people’s needs in a timely way and ensure they got the support needed.

Right care:

• People praised the care they received and had built positive and comfortable relationships with staff.

• People told us they felt staff had kept them safe during the pandemic by following the necessary protocols in place.

Right culture:

• There were opportunities provided for people to be engaged and feedback their views about the home and quality of the service they received.

• People’s care plans and capacity assessments were written in a person-centred way and took into account individual preferences and characteristics of people.

Staff had the knowledge and confidence to identify safeguarding concerns and acted on these to keep people safe. The management team were open and transparent about the incidents reported and had spent time reviewing their processes in place and talking with staff about culture and expectations of behaviour.

Since the last inspection there have been improvements in how medicines are managed. People told us staff supported them with their medicines safely and had no concerns.

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 requires improvement (published 31 March 2020) and there were two breaches of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating. The inspection was also prompted in part due to increased numbers of notifications received to CQC by the service. A decision was made for us to inspect and examine these areas. We found no evidence during this inspection that people were at risk of harm from this concern.

This was a focused inspection which reviewed the key questions of Safe and Well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to good. 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 Voyage (DCA) Wiltshire on our website at www.cqc.org.uk.

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.

Voyage DCA Wiltshire is registered to deliver personal care to people in their own homes or in a shared house arrangement. 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

There were people who at times expressed anxiety and frustrations, using behaviours that placed them, the staff and others at risk of harm. While action plans gave staff guidance, these were not always consistently followed.

Staff were not aware of how to mitigate risks to themselves when managing incidents that placed their safety at risk.

Incident reports were completed where there were behaviours which placed the person and staff at risk. However, there was little evidence of an analysis of the actions taken by staff in relation to known and emerging triggers about the person. This meant there was a lack of consistent approach from the staff. The way staff documented events was not always person centred.

We responded to concerns we received about one person, by undertaking a focussed inspection of Safe and Well-Led. As part of the CQC methodology, we also raised a safeguarding alert with the local authority safeguarding team. Staff acknowledged that they had not always reported poor practice they witnessed from other staff. Once senior managers were made aware of concerns they acted promptly and appropriately. Since the inspection senior managers provided us with further information on safeguarding and whistleblowing procedures.

Some safeguarding referrals were made by the provider, however not all notifiable incidents had been reported to CQC.

People were not fully supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests

The registered manager had requested from commissioners they apply for Court of Protection order. However, the legal framework was not in place to restrict one person’s liberty and for continuous supervision which included 2:1 staff at all times. Staff were not clear on the principles of the Mental Capacity Act and how to apply these to their role. Standard phrases were used in best interest decisions for mental capacity assessment. For example, ‘all restrictions are care planned and accepted.’ This meant there was a lack of person-centred detail in the decisions considered as the least restrictive.

Medicine systems needed further improvements. For example, medicines were identified in the medicine administration record (MAR) as discontinued, but no formal documentation was in place for this. Medicine profiles were out of date which meant that staff didn’t use current guidance on people’s medicine regimes. The recording of “when required” (PRN) medicines were handwritten for one person which was not in line with good practice guidance. The recording of medicines administered were inconsistent and was not identified as part of the audit.

MAR’s detailed the prescribed topical creams although body maps were not in place. Cream and eye drops were not always dated when opened.

Staffing levels were mostly maintained.

The registered manager had recently registered with CQC and since their appointment was being supported by senior managers on developing a plan to progress the service. However, there were improvements needed to gain a better oversight of all services. For example, the systems for monitoring including that for staff performance were not robust.

The quality of service delivery was assessed, but not all shortfalls were identified. Action plans were developed and monitored weekly. However, these did not include the concerns we found relating to medicines systems and reporting processes.

Systems were in place to manage risk. Care plans and risk assessments were combined. We noted where care records were updated the risk assessments were separate from the care plan. The care plans were reviewed, and were mostly person centred, including people’s preferences and support needed from staff.

Recruitment procedures ensured the staff employed were suitable for the role they applied for.

The staff we spoke with were positive about the team and that they shared learning amongst themselves. There was some potential for staff developing their own ways of working instead of following good practice guidance.

Environmental risk assessments were in place. Personal emergency evacuation plans were developed and updated on the actions needed for a safe evacuation of the property. We noted in the communication book where staff often ran out of personal protection equipment. While the location was clean there were some improvements needed for the storage of frozen foods. We recommended the providers seek guidance on the reasonable actions that must be taken to secure improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 10 December 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We received concerns in relation to the care people received. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has not changed. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Voyage DCA Wiltshire on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to care and treatment and to good governance at this inspection.

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.

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Voyage DCA Wiltshire is registered to deliver personal care to people in their own homes or in a shared house arrangement. 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.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People using this service live in single houses of multi-occupation across Trowbridge and Salisbury. Houses of multiple occupation are properties where at least three people in more than one household share a toilet, bathroom or kitchen facilities. Staff support people with personal care, medicines, cooking, shopping, activities and other day to day tasks.

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

Medicine management systems needed further improvements to ensure medicines processes were managed safely. Areas for improvement included clear directions on the administration and applications of prescribed medicines and lotions. Where staff were managing people’s medicines, records of medicines no longer required were not maintained. Recording of medicines received and carried forward were not always documented. Competency assessments had not always been completed for people that administered their own medicines. We have made a recommendation for the provider to seek from a reputable source guidance to develop safe medicine systems.

The quality of service delivery was assessed. Where shortfalls were identified, action plans were developed and monitored by the current peripatetic manager and operations manager. However, not all areas of service delivery were robustly assessed and we recommend that quality monitoring systems are reviewed.

There was an electronic system of recording accidents and incident. Reports were reviewed for patterns and trends. However, there was an incident where staff had not followed the guidance when one person expressed behaviours that challenged the staff. This meant the situation escalated.

Communication support plans lacked detail on how staff helped people understand the personal care that was to be delivered. We recommend that where people have communication needs they are helped to understand their care records by using the most appropriate format. For example, pictures, large print or audio.

A registered manager was not in post. A peripatetic manager was supporting the service and was to continue through the transition of the recently appointed manager.

Safeguarding systems and processes protected people from potential harm and abuse. Safeguarding referrals were made as appropriate. The peripatetic manager reassured us additional training was to be provided to staff who had not shown a clear understanding of these procedures.

Systems were in place to manage risk. Where individual risks were identified combined support plans and risk assessments were in place. Action plans gave guidance on the risk reducing measures.

Although support plans were person-centred we found the quality was variable. People’s abilities and support needs were described but their preferences were not fully detailed. There were people who expressed their anxiety through behaviours that challenged staff and others. Action plans gave staff guidance on how to manage situation during times when people expressed anxiety and frustration.

Environmental risk assessments were in place. Personal emergency evacuation plans gave guidance to staff on the actions needed for people’s safe evacuation from the property. Staff were provided with adequate supplies of personal protective equipment such as gloves and aprons.

Staffing levels were determined by the needs of people. Peoples needs were assessed before the agency agreed to deliver personal care.

The staff attended the training that ensured people's needs were met. New staff had an induction when they started work at the agency. The staff were supported with their performance and personal development. Their performance was monitored through one to one supervision, observations and annual appraisals.

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. Capacity assessments were completed for specific decisions. Where people lacked capacity best interest decision were taken for some people. A mental capacity assessment was not in place to show one person that lacks capacity was able to make decisions about their preferred appearance.

People we spoke with and contacted told us the staff were kind and caring. The staff made people feel they mattered and knew it was important to show compassion. They were knowledgeable about people’s rights and how to respect them. The comments from core staff showed they knew people's preferences.

The staff we spoke with were positive about the team. The strengthening roles and responsibilities of the field support supervisors, the induction programme for new staff and inclusion days has ensured staff feel valued and outcomes for people continue to improve.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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 Requires Improvement (published 4 October 2018) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

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.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. The service used some restrictive intervention practices as a last resort, in a person-centred way, in line with positive behaviour support principles.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults and younger adults who have learning disabilities, autism and/or physical disabilities.

People using this service live in single houses of multi-occupation across Trowbridge and Salisbury. Houses of multiple occupation are properties where at least three people in more than one household share a toilet, bathroom, or kitchen facilities. Staff support people with personal care, medicines, cooking, shopping, activities and other day to day tasks.

At the previous comprehensive inspection, on 12 and 18 July 2017, the agency was rated as requires improvement. We found the service had not complied with Regulations 9 and 11 of the Health and Social Care Act Regulations 2014. We found care plans were not always person centred and did not give staff guidance on how to meet people’s changing needs. We also found the staff were not following the principles of the Mental Capacity Act (MCA). The provider wrote to us, explaining the actions they would take to meet the requirements of the legislation. At this inspection we found some improvements had been made. We made a recommendation about staff attending training in the principles of the MCA.

This is the second consecutive time the service has been rated Requires Improvement.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy.

The current manager was undergoing the process to be registered with CQC. 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.

Medicine systems were not always well managed. Staff that administered medicines had attended appropriate training. We saw records of administration were mostly signed to show medicines administered. For one service, the records of administration were not consistent with the directions noted on the medicines in stock. Also, staff were not always signing records when topical prescriptions, such as creams and lotions were applied. The manager took prompt action to ensure people were having their medicines as prescribed.

The staff were not given clear guidance on when to administer medicines prescribed to be taken. as “when required” (PRN). Where protocols were in place we observed that staff did not follow the guidance or updated the protocols to reflect current practice.

Care plans and risk assessments were combined. Where risks were identified action plans on how to minimise the risk were devised. Care plans had aspects of person centred approach.

Guidance from healthcare professionals to support people’s behaviours, was not always followed. We found that at one service, people did not receive support in accordance with what was recorded in their care plan.

There was an online system of reporting incidents and accidents. However, copies of the incidents were not always completed and a review of the care plan was not triggered for re-occurrences of the same incident. This meant people's needs were not reviewed to develop action plans that prevent or reduce the potential of the same incident from reoccurring.

Staff knew the day to day decisions people were able to make. One person told us the day to day decisions they made. We observed staff giving people choices about their meals and activities.

Mental capacity assessments were not always in place where people lacked capacity to make complex decisions. For example, decisions regarding the use of lap belts, administration of medicines and clothing used to alter behaviours. Members of staff accepted decisions made by relatives on behalf of their family members, without first ensuring they had the legal power to make them.

Quality assurance systems were in place to assess and monitor service delivery. An action plan on improvements was developed from a recent assessment of the service. The manager’s awareness of current risks were not always from process used to monitor and assess system delivery. Some documents had not been analysed and had not been the means used to prioritise or identify where improvements were needed. For example, analysing incidents and accidents. During the inspection we also identified that medicine systems needed improvement in one service. A new format template for weekly meetings with field supervisors was to be introduced to ensure the office staff were aware of people at greatest risk.

The people we spoke with told us they felt safe with the staff. Relatives also felt their family members received safe care. We observed people responded well while in the company of staff and during interactions. Staff told us they had attended safeguarding training. They knew the signs of abuse and the expectations on them to report allegations of abuse

The people we spoke with said the staff were “good”. During our visits we observed the staff addressed people by name and with people participated in activities. Staff knew how to respect people’s rights and relatives said staff were respectful.

One person told us there were staff shortages, but the staff that supported them were regular. Some relatives and staff said there were staff shortages and we noted in one service staff worked long hours.

New staff received an induction to the service, this process ensured they were confident in their role. Staff were positive about the training they received. There were mandatory training sessions for staff to attend as part of their role. The staff we spoke with told us they had regular one to one supervision meetings with their line manager.

Healthcare visits were arranged by relatives, or by field supervisors where necessary. Staff said they were kept informed about visits from healthcare professionals. Copies of healthcare professional’s visits were kept in care files. Health action plans and hospital passports were in place.

When complaints were received, the manager had investigated them according to the policy and procedure. People knew who to contact if they had concerns.

Staff told us they worked well together as a team. The staff were positive about the manager and the improvements that were taking place. However, they told us there had been many management changes and this had impacted on the morale of the staff.

There were links with social and healthcare professionals. These professionals told us their input was sought in a timely manner. We were told of instances when their advice was not followed. However, one social worker told us the staff on other occasions “communicated effectively and completed assessments before an admission to a service. The assessment was thorough and the approach that was used was on the correct level for the person.”

We found a breach of Regulation 12 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.

This inspection took place on 12 and 18 July 2017.

A registered manager was 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.

People’s capacity to make decisions such as medicine administration, finance and personal care was assessed. We saw for people with Court of Protection orders in place the appointed deputies had not been consulted for specific decision. We saw for one person, their relative was managing the finances where there was no Court Appointed deputy in place. The registered manager had not made the Court of Protection aware that they were caring for a person who were deprived of their liberty. Members of staff knew how to support people to make day to day decisions

Copies of records were not kept at the service office which included copies of Healthcare action plans and hospital passports were not kept at the service. Copies of medicine administration records (MAR) and when required (PRN) protocols were not kept at the service. This meant office staff did not have access to people’s information and were not able to give staff guidance over the phone. In addition office staff were not able to monitor records and the effectiveness of the delivery of care and treatment.

Care plans and risk assessments were combined. A traffic light system was used to identify the level of risk. Members of staff knew the actions needed to minimise risks. For example, aggressive and physically challenging behaviour. While some information about people’s preferences was included, the care plans were not always person centred. They lacked detail on how staff were to encourage people to meet their needs. Where healthcare professionals had made recommendations on how to support people these guidelines were not always used to develop care plans. Care plans were not monitored and there was no evidence to show that the care plans were effective.

Some people at times used verbal and physical aggression to show they were distressed or frustrated. A record of these incidents were in place but there was no evidence that all the recommended were followed to prevent the challenging incidents from escalating. Reports of challenging incidents were analysed to see if staff had followed guidance in people’s care plans, or to determine whether care plans needed to be updated.

People told us they received kind and compassionate care from staff. The staff told us how they developed relationships with people and they knew why this was important. The staff comments indicated staff knew people well and knew their preferences.

People told us they felt safe with staff. The staff told us they had attended safeguarding of vulnerable adults training. These staff were aware of the types of abuse and the expectations placed on them to report allegations of abuse.

Recruitment procedures were safe. Where staff had convictions, risk assessments were completed. However, action plans needed to be in place on how these staff were to be supported going forward.

Staff said the training was good and they had attended all mandatory training required by the provider. A combination of face to face and online training was provided. The staff we spoke with said they had regular one to one supervision with their line manager to discuss issues, their performance and training needs.

People’s views were gathered and used to inform the development of the service. Review meetings were used to improve communications between relatives and staff.

Quality Assurance systems were in place to monitor and assess the standards of care, but these were not always effective. Action plans were in place where shortfalls were identified. Although there were similar findings with this inspection, care planning and mental capacity assessments had not been identified by the provider as an area requiring improvement.

The registered manager was aware of their role and challenges of developing a supporting living scheme. Staff told us the registered manager was approachable. They said the team worked well together. They knew their leadership style and challenges with managing a service from a distance.

We found two 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.