This announced comprehensive inspection was carried out on 15 and 18 October, and 2 November 2018. The provider was given 48 hours’ notice as we needed to ensure that key staff were available to participate in the inspection. The inspection activity was completed on 27 November 2018. This was the first inspection of the service since it registered with the Care Quality Commission on 10 October 2017. Greenwrite Heathcare is a domiciliary care agency which provides the regulated activity of ‘personal care’ to people living in their own houses and flats in the community. The Care Quality Commission (CQC) only inspects the service being received by people provided with personal care; help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of the inspection the provider was providing personal care services for five people.
There was a registered manager in post at the time of our inspection, who was present during the inspection. A registered manager is a person who has registered with 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 is the owner of the service.
We found the provider had not ensured that people were protected from the risk of receiving their care and support from staff who did not have suitable knowledge and experience to carry out their roles. The recruitment practices were not sufficiently detailed and the registered manager had not adequately followed up conflicting information about an employee’s background and other discrepancies in references. Although staff had been provided with safeguarding training, the whistle blowing policy did not contain full guidance for staff about how to progress any concerns relating to the conduct of peers or supervisory and managerial staff. The registered manager did not demonstrate a complete understanding of the legal necessity to inform the CQC of any allegations of abuse and neglect.
The member of the care staff we spoke with confirmed they had appropriate access to personal protective equipment to protect people from the risk of cross infection, however one relative reported that this equipment was not always available for staff to protect their family member. Risk assessments were in place to identify and mitigate risks to people’s individual safety and the safety of their home environment. The provider had taken action following a serious incident when a person did not receive the care and support they needed to meet their essential needs, due to a communication error by a staff member.
Records showed that staff had received induction, mandatory training and supervision. However, some of these records had been altered with correcting fluid, which was not consistent with record keeping that needs to clearly demonstrate when staff received support from their line manager to understand and achieve the knowledge and skills needed to appropriately meet the needs of people who used the service.
Some of the care and support plans we looked at showed that people’s nutritional and health care needs were met by their relatives. Where people required staff support we found that their care and support plans provided guidance for staff and information about people’s preferences. At the time of the inspection we noted that people who used the service had capacity to sign consent forms and agree to the contents of their care and support plans. The design of the consent forms indicated that the provider would not permit a relative to sign on behalf of a person who did not have capacity, unless they had the legal powers to do so. However, relatives and friends could separately sign to evidence that they had been consulted as part of the care planning process.
We received satisfactory comments about the quality of the service and how staff supported a person from the professional representative of one person. However, the relatives of other people told us that they had been alarmed at times by the lack of professional behaviour by staff and the inability of the registered manager to have initially recruited staff with appropriate dispositions, integrity and skills to work with people who used the service. Relatives described how people had not been supported in a dignified way to receive their personal care and how polite and diplomatic boundaries had not been respected by staff within people’s homes.
People were provided with information about how to make a complaint and guidance about advocacy services, although further details were required to enable people to choose which advocacy organisation they might wish to approach.
The care and support plans we looked at had been in place for a short time as the provider had begun supporting people in Essex and no longer had local people in the London Borough of Southwark. Therefore, we could not ascertain how the provider reviewed and updated people’s care and support plans. Given that some people who used the service had end of life care needs, we would expect that their needs could change quickly due to their diagnosis and frailty.
The provider’s own investigations of complaints did not fully explore whether there were shortfalls at the service that had contributed to people not receiving the quality of care and support they should expect.
At the time of the inspection some people were receiving end of life care. We noted that the provider could source bespoke training to support people with specific needs, for example staff could receive external training about how to use specific equipment including enteral feeding apparatus. However, we did not find evidence that staff had end of life care training of a meaningful quality as part of their mandatory training programme.
Relatives expressed that the management of the service was “disorganised” and “chaotic.” This partly stemmed from the distance that some care staff travelled to reach people in Essex, which concerned relatives as it sometimes impacted on punctuality when difficult travel conditions were beyond the control of members of the care staff. The registered manager informed us that she was recruiting more staff in the Chelmsford area and monitoring when it could be necessary to apply to CQC to open a new location in the area, so that care staff could have better systems of local support.
Information published on the provider's website did not provide current information about how they met the needs of people who used the service.
We saw that spot checks were being carried out, however relatives reported that the standards of care fell below their minimum expectations. The quality of care and support and the type of concerns we heard about the service demonstrated that the provider’s own quality monitoring systems were not identifying and addressing problems at the service.
We have made one recommendation that the provider seeks guidance to improve the quality of recording on people’s medicine administration records (MAR) charts. We have issued three breaches of regulation in relation to the provider not ensuring the safe recruitment of staff, the failure to notify the CQC of any allegations of abuse in line with the law and the provider’s lack of robust monitoring to detect and address issues of concern that impacted on the quality of care and support for people who used the service.
You can see what action we told the provider to take at the back of the full version of the report.