Athlone Care

Athlone Care is a domiciliary care agency, providing personal care to 58 people at the time of the inspection. 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

The service people received was not always safe. Concerns had been raised with CQC before the inspection in relation to the timings of people’s care and the hours staff were working. We found evidence the concerns were founded. The provider could not be sure people were receiving the care they needed at the right times as records were not closely monitored.

Systems to monitor the quality and safety of the service did not evidence the provider could make and sustain improvements to people’s experience of care in their home. There were mixed views from people and their relatives about the responses they received from the office and management team.

Complaints and concerns needed a more robust approach to evidence people were listened to and action was taken when they raised concerns about their care. We have made a recommendation about this.

Plans were in place to mitigate individual risks. People’s medicines were administered and managed safely by staff. Staff understood their responsibilities in keeping people safe and reporting concerns if they had them, including accidents and incidents. The provider kept staff up to date with the latest guidance around infection control through meetings and social media messaging.

People, and their relatives where appropriate, were involved in planning their care. Care plans provided the information staff needed to provide people’s care in the way they wanted it.

Staff we spoke with were positive about the support they received from the provider and registered manager, saying they could speak to them about anything and were confident about their response. The provider and registered manager engaged well with local services and commissioners.

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 good (published 5 January 2019). The service has now deteriorated to requires improvement.

Why we inspected

We received concerns in relation to staffing concerns including missed and late care visits and the providers response to complaints and concerns. As a result, we undertook a focused inspection to review the key questions of safe, responsive 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 good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe, responsive and well-led sections of the full report.

You can see what action we have asked the provider to take at the end of this report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified one breach of regulation, in relation to accurate record keeping and oversight and monitoring at this inspection.

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

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.

Not everyone using Athlone Care receives regulated activity; 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 take into account any wider social care provided.

The service was run by a registered manager who was present at the inspection visit to the office and home visits. 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 the last inspection on 25, 26 and 30 October 2017, the overall rating of the service was ‘Requires Improvement. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because records, including those about people’s care, were not always accessible, up to date and accurate. We asked the provider to send us a plan setting out the actions that they would take to meet this legal requirement. The provider returned the action plan within the agreed timescale and told us they had already met the breach of regulation.

At this inspection on 3, 4 and 5 December 2018, we found that the provider had made the necessary improvements to record keeping. Records were accurate and available to people who needed them.

People felt safe whilst being supported by staff. Staff had received training in how to safeguard people, knew what signs to look out for which would cause concern and how to report them.

Assessments of potential risks in the environment and with regards to people’s health and welfare had been carried. Guidance and strategies had been developed which staff followed to protect people from avoidable harm. Accidents and incidents were monitored to see if there were any trends or if lessons could be learned.

Suitable recruitment checks were in place for new staff. People had their needs met by regular staff who were available in sufficient numbers.

Staff had received training in how to give people their medicines and medicines were audited to make sure people received their medicines as prescribed by their doctor.

New staff received an induction which ensured that they had the skills they required, before they started to support people in their own homes. Staff continued to undertake training in essential areas and their practice was observed to ensure they were competent.

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.

The provider assessed and monitored people’s health and nutritional needs. Staff were given pocket guides about different medical conditions to which they could easily refer. The provider worked in partnership with people and their family members to make sure people accessed the health care services they needed.

People's needs were assessed before they were provided with a service. Care plans were personalised and gave guidance to staff about how to care for each person's individual needs and routines. Staff knew people well and treated people with kindness and respect.

Relatives and people were informed of their right to raise any concerns about the service. The provider monitored complaints to see if there were any patterns or trends or lessons learned.

Quality assurance systems had been strengthened so the provider had clear oversight of the running of the service. People’s views about the service were sought and acted on.

People and their relatives thought that the service was well run and said that they would recommend it.

Athlone Care Ltd is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community in Bexley and surrounding areas. It provides a service to older adults, including people with physical and learning disabilities. At the time of the inspection the service was providing care for 11 people.

At the last inspection on 7 June 2017 the service was rated as inadequate overall and placed into special measures. We took enforcement action and served two warning notices which required the provider to make improvements by 21 July 2017 in the management of medicines, the assessment and management of potential risks to people’s health and safety, and the systems in place for monitoring the quality of the service. These were continued breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also required the provider to take action to make improvements so that care plans reflected people's assessed needs and preferences, that there were effective systems to monitor potential safeguarding incidents, that any complaints were responded to and that staff were deployed so people received the care they needed when it was required. These were breaches of Regulations 9, 13, 16 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to send us a plan setting out the actions that they would take to meet these legal requirements by 17 July 2017. The provider informed us there would be a delay in providing this plan which was received on 17 October 2017. In this plan the provider told us they had met or taken initial action to meet all breaches of regulations.

At this inspection in October 2017, we found improvements in most areas, but there remained a continuous breach in record keeping and two recommendations were made to drive improvements.

The service was run by a registered manager who was also the registered provider and they were present on the days of our visit. 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.

Some records in relation to people’s care and treatment and the running of the service continued to be inaccurate and unavailable when staff needed them.

Most people said there had been improvements in the timeliness of staff so that they arrived when they were expected. However, three out of nine people said that on occasions staff continued to be up to one or two hours later than they anticipated. We asked the provider to investigate and have made a recommendation about this. .

People were informed of their right to raise any concerns about the service and these had been recorded and acted on. However, people and their relatives had mixed views about how responsive the service was to their complaints. We have made a recommendation about this.

The values and aims of the service were not consistently delivered as there were mixed views on whether the service was well managed and if people would recommend it to other people.

Comprehensive employment checks were carried out on all potential staff at the service, so they were suitable for their role.

People felt safe whilst being supported by staff. Staff had received training in how to safeguard people, knew what signs to look out for which would cause concern and how to report them. Staff carried pocket card reminders so they knew the appropriate action to help keep them safe.

A new framework had been established to assess potential risks in the environment that people lived and worked in and in relation to people’s personal care needs. This included potential risks involved in moving and handling people, supporting people with their personal care needs and with managing medicines. Guidance was in place for staff to follow to make sure that any risks were minimised. A new system was in place to record, monitor and assess all accidents and incidents to make sure that the necessary action had been taken to keep people safe.

A medicines policy was in place to guide staff. Staff received training in the administration of medicines. Improvements had been made in the management of medicines so there was a clear recording and monitoring of each medicine a person was given.

New staff received an induction which ensured that they had the skills they required, before they started to support people in their own homes. Staff continued to undertake face to face training in essential areas, their practice was observed and they shadowed senior staff to ensure they were competent. Staff had been given pocket guides and received regular updates on areas essential to their role such as skin integrity, safeguarding and The Mental Capacity Act (MCA) 2005. Most people said that staff had the skills and knowledge they needed to support them.

Staff had undertaken training in MCA 2005 and the provider had strengthened their knowledge through giving them additional updates. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals, where relevant.

Improvements had been made to the way people’s health care and nutrition needs had been assessed and guidance was in place for staff to follow, to ensure their needs were met. A record was kept of people’s food and fluid intake when they supported people with meals.

People said that staff were kind and caring and treated them with dignity and respect.

The provider had developed a new assessment and care planning process which included people’s individual needs, choices, and encouraged people to be as independent as possible.

Improvements had been made to monitoring the quality of the service which included asking people about their experiences.

The service had a registered manager in post. A registered manager is a person who is 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.

We last inspected Athlone Care in May 2016 when two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. We issued requirement notices relating to safe care and treatment and good governance. We made multiple recommendations including recommending the provider considered reviewing staffing levels to ensure that people's needs were being fully met and recommending that the provider ensured staff had a clear understanding of The Mental Capacity Act 2005 and how this needs to inform care.

At our inspection in May 2016, the service was rated 'Requires Improvement'. We asked the provider to take action and the provider sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. The provider had not met the previous breaches of regulations and further breaches were found.

There was a lack of scrutiny and oversight by the registered manager to ensure that people received safe care and treatment. Staff documented that people had fallen or had visits from health care professionals in people’s daily notes but did not call to inform the office so that any follow up action could be taken. The management team did not regularly review people’s daily notes so they were unaware of changes to people’s support or incidents that occurred and did not follow them up to ensure that appropriate action had been taken.

People’s care plans did not contain the detail needed to keep people safe including guidance for staff about how to reduce the risk of pressure sores. One person had developed a pressure sore and although staff had asked the person’s relative to contact a district nurse, they had not informed the office for over three days. They had not recognised the development of a pressure sore could be a potential safeguarding issue. Another person had become unwell and staff had told their relative to contact a doctor for advice. This had not been reported to the office, so the management team were unable to monitor and assess if appropriate action had been taken.

Some people needed assistance with eating and drinking. One person told us that they had specific dietary needs to help manage their health condition. This was not recorded in their care plan and the registered manager told us they were ‘unaware’ of this person’s needs. Care plans also lacked information on how to support people to move safely or remain independent. People’s care plans had been sampled and checked by the registered manager, but these checks had not identified these shortfalls.

People’s medicines were not always managed safely. Staff did not consistently record when they administered medicines. Medicine records had not been reviewed or checked by the management team, so these issues had not been identified.

Staff reported accidents and incidents to the office however, the management team did not review them to ensure appropriate action had been taken and to reduce the risk of incidents happening again

People and their relatives told us that staff were consistently late when providing support. The provider’s analysis showed that in April 2017 over 244 care and support calls to people had been more than half an hour late. The provider had asked for feedback from people, their relatives and other stakeholders involved in the service and this had identified that staff were often late too. People told us they had complained when staff had been late, but there was no record of these complaints at the office. Without a record of these complaints and the themes and outcomes, there was a risk that the registered manager would not be aware of them and therefore, not use this to improve the service.

Staff did not follow the principles of The Mental Capacity Act 2005. Some people’s relatives had signed to consent to the care provided by the service, even though the registered manager told us that these people had capacity to consent themselves. Some people were documented as being ‘confused’ but there had been no assessment of their capacity and no advice for staff on how to support people to make decisions.

People did tell us that staff were kind and caring, and when they offered support treated them with respect and dignity.

All staff were working towards completing The Care Certificate, which is an identified set of standards that social care workers work through based on their competency and vocational diplomas in Health and Social Care. They had received additional, online training in topics relating to people’s needs such as dementia. Staff had received ‘spot checks’ when supporting people to assess their skills and competencies. The registered manager had ensured that staff were recruited safely and that the Care Quality Commission had been notified of events, as required by law.

Staff told us they knew how to recognise and respond to abuse and what action they would take to report any concerns. However, staff had not reported potential incidents of neglect, such as the development of a pressure sore to the registered manager.

We found a number of 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 the 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.=

Athlone Care is a domiciliary care agency which provides personal care to people who live in their own home, including people with dementia and physical disabilities. The service provides care for people in Tower Hamlets, Bexley and North Kent area. There were 37 people receiving support to meet their personal care needs on the day we inspected.

The service had a registered manager who was also the registered provider. 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.

Most people we spoke with were positive about the service provided. We were unable to speak to relatives of people receiving care.

The service was not always safe. People were not protected from the risk of medicines management. Staff were not appropriately trained to administer medicines however, staff were administering medicines to people. The provider and staff were not following their own policy in relation to the management of medicines.

Not all risks to people had been identified and assessed. Care plans contained contradictory information in relation to risk. Risk assessments did not go on to show how risk could be mitigated.

Recruitment practices were not always safe. Gaps in employment history were not always explored. We have made a recommendation about this.

Feedback from health care professionals over staffing levels was not positive. Senior staff told us that they never committed to care packages unless they were certain they had the care staff available. We have made a recommendation about this.

Accidents and incidents were responded to appropriately.

Staff training was not always up to date but the provider had made a commitment to put all staff through the Care Certificate training regardless of the length of service with the company. Training was managed via supervisions and they had recently recruited an in house trainer for the service. Staff received supervision and appraisals and were suitably supported to carry out their roles.

Staff did not have a clear understanding of the Mental Capacity Act 2005 (MCA) and how this informed care. The provider had policies in place for MCA and for the Deprivation of Liberty Safeguards (DoLS). However, DoLS do not apply in a community based setting and therefore the policy was not relevant or fit for purpose. We have made a recommendation about this.

People were encourage to maintain a healthy and nutritious diet and daily care records showed that where there were concerns over people’s diet food and fluid intake was recorded. People were also supported to access health care professionals such as district nurses and their GP’s.

The service was caring and staff knew people they were caring for well. Staff were able to tell us how they respected people’s dignity and privacy. People’s cultural and religious needs were respected. Staff of the same religion or those that spoke the same language as people were matched to people to enable them to be supported..

People were generally supported by regular care staff for the purpose of continuity.

People were provided with a service user guide that set out what people could expect from the service. However, this was not available in an alterative format. We have made a recommendation about this.

People’s care records were kept confidentially on a password protected IT system.

People had pre assessments carried out that fed into care plans which they had been involved in drawing up. Care plans were not person centred and did not contain details of people’s likes and dislikes. The provider was in the process of transferring care plans over to a new system which was person centred. Care plans had been reviewed on a regular basis with the involvement of people. .

The provider had a complaints policy in place that set out how people could make a complaint if they needed to.

The provider had not carried out a recent customer satisfaction surveys. The feedback we received from people around the management of the service was mixed. Some people felt that it was well led. Health care professional felt that it could be better led.

The provider was not carrying out any quality assurance monitoring or audits of the service.

Communication to staff was via email although some staff told us and staff survey’s showed that communication was not always effective. Care staff told us that there were issues with the office and the on call system. We have made a recommendation about this.

The registered manager was able to tell us about their role and responsibilities and were aware of the obligations in reporting incidents to the Care Quality Commission. The registered manager told us that they were building an experienced and qualified team at a senior management level to help support them to make changes and improve the service.

The registered manager kept up to date with best practice and also sought support from their peers in the industry.

The registered manager and senior staff were clear about what the visions and values of the service were. Care staff demonstrated the values when they described the care they provided.

We found 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.

During this inspection, the inspector focused on answering our five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and the staff told us. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that people who used the service were protected from the risk of abuse because all care staff were trained in the safeguarding of vulnerable adults and in the principles of the Mental Capacity Act 2005. All staff had been subject to Disclosure and Barring Services (DBS) checks before they started work. We found risk assessments with clear action plans were in place to ensure people remained safe. People's consent to care and treatment was sought appropriately and people's care records were kept securely. Staff monitored people's health and referred to health professionals or alerted emergency services when necessary.

Is the service effective?

People and their relatives told us they were very satisfied with the quality of care that had been delivered. We looked at ten people's assessment of needs and support plans and we checked with people who used the service that the delivery of care was in line with their care plans and assessed needs. We found that people's needs were re-assessed when needed and that their care plans were adjusted to reflect changes in needs. People who used the service commented, "My requirements are quite specific and are being respected by the care workers who are very understanding" and "The staff are ever so kind and nothing is too much trouble". We found that the staff had received the training they required to meet the needs of people who used the service and that additional training was available.

Is the service caring?

We found that people who used the service were supported by kind and attentive staff. All the people who used the service that we spoke with were complimentary about the care workers' approach and attitude. One person who used the service told us, "The care workers are so caring, kind and considerate". A relative of a person who used the service said, "My family member and the care workers have developed a good rapport and the care workers treat her with respect and kindness'.

Is the service responsive?

People's needs had been assessed before care and support began and their care plans were reviewed regularly to reflect any change of needs. We saw that people's care plans included their history, wishes and preferences. People and/or their representatives were involved with reviews of care plans. People's views were sought about the quality of care that they received and their views were taken into account. A relative of a person who used the service told us, "I have raised minor complaints with the deputy manager and each time they responded promptly and made alterations to put matters right ". A member of staff told us, 'If I have cause to raise any concerns I am confident that they will be taken seriously and acted on'.

Is the service well-led?

We found that the registered manager had a system of quality assurance in place to identify how to improve the service. People and their relatives or representatives were regularly consulted about their level of satisfaction and survey questionnaires were provided, collected and analysed. We saw the service operated an 'open door' policy where staff were encouraged to express their views. Two members of staff told us, "This is a good company to work for, we are part of a good team", and "The manager, the deputy manager and the care assessor are very approachable, we can raise any concerns without fear". The registered manager told us, "We make sure good standards are maintained and take appropriate action if they are not". Staff's practice was regularly observed and monitored to check good care practice was maintained and to identify whether additional training or refresher courses were needed.

We saw that people's consent was obtained where possible before care and treatment was undertaken. We observed that the care given was safe and appropriate and based on effective care planning and risk assessments. This meant that people's individual needs were met and preferences were taken into account.

People were protected from abuse and cared for in a safe and inclusive environment. We also noted that people were cared for, or supported by, suitably qualified, skilled and experienced staff. In addition, the provider had an effective system to regularly assess and monitor the quality of service that people received.