Care at Home (Swindon)

Care at Home (Swindon) is a supported living service providing the regulated activity of ‘personal care’ to people with a learning disability, autistic people and other people with complex needs in their own houses. Not everyone who uses the service received personal care. This is help with tasks related to personal hygiene and eating. Where they do, we consider any wider social care provided.

At the time of the inspection, 39 people were receiving personal care in eight different supported living settings. We visited some people who lived in adapted houses where people had their own bedrooms and sometimes individual or shared bathrooms, as well as shared communal areas. People received a variable number of care hours per week, depending on their assessed needs.

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.

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

The service was not able to fully demonstrate, across all supported living settings, how they were meeting some of the underpinning principles of Right support, right care, right culture. People did not always receive consistent good standards of care.

Right Support

Two out of three premises had deregistered from residential to supported living and did not always maximise people’s choice and independence. There needed to be more focus on continuously developing meaningful activities, independence and quality of life. The provider had identified this and employed an external consultant to help drive improvement with staff in the way of ‘on the job’ training, guidance and role modelling to ensure improvements were made.

Some features in these premises were similar to a 'care home' and did not meet guidance in respect of having good access to the local community and its amenities. They were geographically isolated and the lack of public transport and staff who were drivers meant people were not always supported to be as independent as they could be. The provider was undertaking improvements in two of the settings to improve accessibility such as new kitchens.

There were not always enough staff to meet people's preferences with how they wanted to spend their day and do things they wanted outside of their homes. At one of the settings, the provider was delivering the support hours currently commissioned, but had requested, and were awaiting outstanding needs assessments for people from all relevant funding authorities. This was to ensure staff numbers accurately reflected people’s needs including social preferences, so they had support to do things they wanted outside of their homes.

At two of the three previous care homes that had now become part of the supported living scheme, we found people were sometimes placed at risk of avoidable harm. Risk assessments were inconsistent and did not always detail the relevant information staff would need to meet people's assessed care and health needs. The provider had put processes in place to address these areas of concern, but not all had been identified prior to the inspection. A new manager was in post and an action plan was being worked through to address the concerns. The provider was updating all relevant bodies of actions taken.

Right Care

We found no evidence that people had been harmed, however, there were failures to record, monitor and improve the quality and safety of the service, and failure to maintain accurate records. We also identified concerns around the safe management of medicines and risks in two of the supported living premises. The provider was addressing these concerns and an action plan in place to track improvements.

We observed positive interactions between people and staff. People were comfortable approaching staff when they needed support and we observed staff respected people's choices.

People or their relatives felt comfortable in raising issues or concerns. There were systems and processes in place to safeguard people from abuse.

People were not always supported to have maximum choice and control of their lives. The practices in some supported living settings did not always support people in their best interests.

Right culture

The provider had not always evidenced that leadership had ensured people were supported in a culture that supported leading inclusive and empowered lives. However, the provider had identified the need to improve the culture in one of the supported living settings and was in the process of embedding improvements with the aim of embedding these to ensure consistent high-quality care. The provider was working with external stakeholders to improve people's lives consistently across the service. The provider had also appointed a Regional Operations Director and Operations Support Manager to ensure that a significant amount more oversight was available in the settings to ensure that the settings delivered in line with the providers minimum expectations of good.

All staff we spoke with displayed caring and person-centred values and a commitment to make the necessary 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 outstanding (published 26 June 2019).

Why we inspected

The inspection was prompted, in part, due to concerns about one of the settings received from a local authority. This was in relation to people’s care and safety including risk assessments and care records not being updated, staff training and levels of staff. The overall rating for the service has changed from outstanding to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Responsive 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 Care at Home (Swindon) 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 and will take further action if needed.

We have identified breaches in relation to safe care, person centred care, and good governance 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, which will help inform when we next inspect.

People’s experience of using this service:

The service was exceptional in placing people at the heart of the service with a strong person centred, caring and responsive ethos. People consistently told us how they were treated with exceptional kindness, compassion and respect. We received many accounts of people’s views of their support. Comments from people and relatives included, "It’s a happy home. I love it here" and "I believe they are outstanding for their overall care package. My [relative] is treated like she is in a family”.

People's needs and wishes were fully supported by staff that knew them well. People were respected and valued as individuals; and empowered as partners in their care in an exceptional service.

People received exceptionally personalised care and support specific to their needs and preferences.

People’s needs were considered and reviewed and changes made where improvements were needed. People were supported to engage in decisions in respect of who they lived with and which staff supported them. Each person was respected as an individual, with their own social and cultural diversity, values and beliefs.

Staff were skilled, motivated and knowledgeable. They provided flexible care and support in line

with a person's needs and wishes. The stability of the staff team helped to ensure people felt cared for, understood and supported to achieve positive outcomes.

The service was well-led which was evidenced by the findings of the inspection in the caring and responsive key questions. The registered manager demonstrated how their approach to supporting people provided a positive role model for all the staff. They were supported by a senior team and staff who were fully committed to delivering quality person-centred care to people. Staff were motivated by and proud of the service and morale was very high.

The registered manager showed a passion to improve the model of supported living and had taken measures to integrate best practice standards into the delivery of care. The registered manager was clear about their expectations relating to how the service should be provided and led by example.

The service continued to have a robust quality assurance system which had sustained continual development and improvement at the service. They had demonstrated ways of working that ultimately improved the outcomes for people they supported.

People were supported to have maximum choice and control of their lives and supported them in the

least restrictive way possible; the policies and systems in the service supported this practice.

Rating at last inspection: Outstanding. Report published 8 November 2016.

Why we inspected: This was a planned inspection based on the rating at the last comprehensive inspection. The service continues to be rated Outstanding.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our inspection schedule for those services rated as Outstanding.

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

There was an experienced and committed registered manager in post whose aim was to find ways to enable staff to provide safe and responsive care to people that use 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.

The registered manager placed safety at the forefront of everything. Robust systems and processes were in place to ensure people’s safety. The provider had also put in place extra support in the way of implementing various innovative and proactive measures. For example, regularly changing key pad codes and putting up posters for people that did not want ‘Trick or Treat’ visits around Halloween. The registered manager and care workers knew what to do if they suspected someone was being abused or harmed. Recruitment practices were robust and contributed to protecting people from staff who were unsuitable to work in adult social care. The registered manager ensured medications were safely managed. They liaised with individual professionals to ensure the effective management of this and to reduce anxieties of people. People received their medicines as prescribed.

People received outstandingly effective care as staff were trained, experienced and supported to offer care to people over and above expectations of their role. Staff had received a wide range of training so that they had a good understanding of how to meet people’s needs. The registered manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA provides a legal framework to assess people’s capacity to make certain decisions, at a certain time. Staff were clear about the importance of gaining consent from people. People told us their wishes and decisions were respected.

Staff made sure if people became unwell, they were supported to access healthcare professionals for treatment and advice about their health and welfare. They did this in partnership with people and provided full information for people to help them understand their health needs.

People received compassionate care and respect from staff that valued them as individuals. Relatives described staff as excellent and who went out of their way to support people to achieve their expressed wishes. Staff were respectful of people’s privacy and dignity.

People’s dietary needs were monitored and referrals to professionals such as a dietician were made when appropriate.

People received a good level of care that was responsive to their individual preferences and needs. The provider had a strong commitment to ensuring people in the service received individual person centred care. Documentation was meaningful to the person and provided a personal glimpse of the person and the life they wanted to live and their history. People and their relatives described a staff team that were able to support individuals in a caring and effective way.

Management and staff understood the importance of responding to and resolving concerns quickly. People felt confident they could raise any concerns to the management.

The service was well led by a management team committed to providing an excellent service to both people receiving domiciliary care and those in supported living accommodation. Staff told us that the management led by example and was supportive and easy to talk to. The management was responsible for monitoring the quality and safety of the service, and had done so consistently.

The service asked people for their views about the day to day care they received through surveys and reviews held every six months. People’s thoughts and expectations led improvement to the service they received. This meant the registered manager acted on feedback received to continuously improve the service. The provider’s outlook was reflected in the way this service was run and they included the people who used the service in decisions about how the organisation was run.

We spoke with three relatives and three people who used the service. They told us that they, or their relative had been involved in developing their care plans, for example by saying what support they needed and when. All six people said that they had been given information about the service and there was their or their relative's care plan in their home.

There were safeguarding procedures and staff had received training so that people were protected from abuse. Staff had also received a range of training and they were supervised and supported so that they could meet people's needs.

One relative said that care staff had 'all been lovely' and another relative said staff would 'go out of their way to help'. All comments made by relatives and people were positive.

We saw positive feedback from people in the satisfaction survey that had been sent out in April 2013. We noted that there were 27 responses from people who used the services and generally the service was very well received. At that same time a staff survey was completed and we noted that the responses they made were positive.

People and their representatives were asked their views about the service and these were listened to and acted upon. There was a system to monitor the quality of the service that people received and to make improvements when needed.