Capital Homecare (UK) Limited

Capital Homecare (UK) Limited is a domiciliary care agency. It provides personal care to people living in their own houses and flats. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is to 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, 207 people were using the service.

People’s experience of using this service:

Some people were not supported by effectively deployed staff to keep people safe and to meet their needs in a timely manner. The quality assurance system was not robust; as the provider had not always identified some of the issues we found at this inspection, in relation to staff deployment, late calls, call monitoring and management of people’s medicines about recording.

At our last inspection we recommended the provider giving sufficient care tasks details and guidance for staff in the care plan, alongside people’s choices and preferences. At this inspection we found the provider had made sufficient improvements. Staff showed an understanding of equality and diversity. Staff respected people’s choices and preferences. People knew how to make a complaint. The registered manager knew what to do if someone required end-of life care.

People and their relatives gave us positive feedback about their safety and told us staff treated them well. People were protected from the risk of infection. Staff received support through training, supervision and staff meetings to ensure they could meet people’s needs. Staff told us they felt supported and could approach the management team members at any time for support.

Staff asked for people’s consent, where they had the capacity to consent to their care. 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.

An assessment of people’s needs had been completed to ensure these could be met by staff. People and their relatives were involved in making decisions about their care and support. People were treated with dignity, and their privacy was respected, and supported to be as independent in their care as possible.

There was a management structure at the service and staff were aware of the roles of the management team. They told us the registered manager was supportive and approachable.

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 01 October 2021). At that inspection we found breach of regulation in relation to good governance. 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 in relation to detailed care plans with sufficient guidance for staff. However, we found the provider was in breach of regulation 18 and remained in breach of regulation 17. The service remains rated requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Enforcement and Recommendations

We have identified breaches in relation to staffing and good governance. At our last inspection we recommended that the provider keeps a record for administration of PRN (as required) medicine on each occurrence where a member of staff has supported with its use. At this inspection we found the provider had not made sufficient improvements.

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.

Capital Homecare Limited is a domiciliary care agency. It provides personal care to people living in their own houses and flats. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is to 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 356 people were receiving personal care.

People’s experience of using this service:

The quality assurance system was not robust, as the provider had not always identified some of the issues we found at this inspection or acted upon them in a timely manner in relation to medicines management and developing comprehensive care plans.

We have made two recommendations about the management of some medicines and care plans.

People and their relatives gave us positive feedback about their safety and told us staff treated them well. The service had systems and processes in place to administer and record medicines use. Some specific medicines with additional administration requirements were not captured in care plans and risk assessments. People’s care plans reflected their current needs; however some care plans were not detailed with sufficient guidance for staff. People were supported by effectively deployed staff and their visits were monitored. The provider carried out comprehensive background checks of staff before they started work. people were protected from the risk of infection. The provider had a system to manage accidents and incidents.

Staff received support through training, supervision and appraisal to ensure they could meet people’s needs. Staff told us they felt supported and could approach the management team members at any time for support. The provider worked within the principles of Mental Capacity Act (MCA). Staff asked for people’s consent, where they had the capacity to consent to their care. 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.

An assessment of people’s needs had been completed to ensure these could be met by staff. The management team and staff worked with other external professionals to ensure people were supported to maintain good health. People and their relatives were involved in making decisions about their care and support. People were treated with dignity, and their privacy was respected, and supported to be as independent in their care as possible.

Staff showed an understanding of equality and diversity. Staff respected people’s choices and preferences. People knew how to make a complaint. The registered manager knew what to do if someone required end-of life care.

There was a management structure at the service and staff were aware of the roles of the management team. They told us the management team members were supportive and approachable. The management team members and staff worked as a team and in partnership with a range of professionals and acted on their advice.

Rating at last inspection and update

The last rating for this service was good (published 08 March 2018).

Why we inspected

We received concerns in relation to the leadership and management of the service. As a result, we undertook an inspection to review the key questions of safe, effective, caring, responsive and well-led.

Enforcement

We have identified a breach in relation to effective quality assurance systems and processes at this inspection.

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 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.

At the time of the inspection, 426 people were receiving personal care and support from this service.

There was a registered manager 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.

At the last comprehensive inspection we carried out on the 27 February 2017 and 01 March 2017, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We received an action plan from the provider which showed what they would do and by when to improve the key questions, is it safe, is it effective, is it responsive and is it well led to at least Good. During this inspection, we found that the service had taken appropriate action to improve on and meet the breaches of regulations we previously identified.

At our previous inspection we found complete records had not been maintained in relation to the support people needed with their medicines. During this inspection we found that the service had taken steps to address this. Records showed Medicines Administration Records (MARs) were completed fully and people’ s care plans clearly outlined the level of support people required with their medicines. There were medicines audits in place which identified any discrepancies and highlighted better practice. Staff had received medicines training and policies and procedures were in place.

At our previous inspection we found consent had not been obtained in line with the requirements of the Mental Capacity Act 2005 (MCA). During this inspection the service had taken steps to address these issues. Records showed where a person lacked the capacity to make a specific decision, people's families were involved in making a decision in the person's best interests. Care plans were signed by people or their representative to indicate that they had consented to the care provided. There was a MCA policy in place and staff had received training on the Mental Capacity Act 2005 (MCA). Staff understood the implications of the MCA and were aware of the importance of obtaining people's consent regarding their care and support.

At our previous inspection, we found systems for monitoring the quality and safety of the service were not always effective. During this inspection, we found that the service had taken steps to address this. The service had updated their quality assurance systems and undertook a range of checks and audits of the service. Spot checks were conducted to assess staff performance and competency. People and relatives spoke positively about the way the service monitored the quality of care they received.

The service also obtained feedback about the quality of the service people received through review meetings, telephone monitoring and satisfaction surveys. Records showed positive feedback had been provided about the service.

At our previous inspection, we found records of staff members' full employment history and consideration of any gaps in employment had not been maintained. During this inspection, we found that the service had taken steps to address this. Records showed any gaps in staff members employment had now been accounted for. Appropriate recruitment checks has been undertaken to ensure people were safe and not at risk of being supported by staff that were unsuitable.

Processes were in place to help protect people from the risk of harm and staff demonstrated that they were aware of these. Staff had received training in safeguarding adults and knew how to recognise and report any concerns or allegations of abuse. Risks to people were assessed and identified according to people’s specific needs.

There was consistency in the level of care people received. People and relatives told us staff turned up on time and they received the same staff on a regular basis. The service had an electronic monitoring system in place to monitor calls delivered and staff punctuality. However we found some late calls were not being followed up and there were no records which showed action taken to ensure staff attended their visits. During the inspection, the registered manager implemented a procedure for office staff to use and we saw evidence that late calls were followed up and any action taken had now been recorded.

People and relatives spoke positively about the staff and told us they did their jobs properly and had confidence they were well trained and had the right skills. Staff spoke positively about their experiences working for the service.

Staff had a good understanding of the importance of treating people with respect and dignity. Feedback from people using the service and relatives was very positive and showed positive relationships had developed between people and staff and people were treated with dignity and respect.

Staff were informed of changes occurring within the service through regular staff meetings. Staff told us that they received up to date information and had an opportunity to share good practice and any concerns they had at these meetings.

People received care that was responsive to their needs. People's daily routines were reflected in their care plans and the service encouraged and prompted people's independence. Care plans included information about people's preferences. However we noted some inconsistencies in the level of detail in people’s care plans. The registered manager told us that some care plans were not as detailed as the person had capacity and did not need any extensive support however they would ensure care plans were reviewed and updated to ensure consistency.

There was a registered manager in post at the time of our inspection. 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.

We inspected the service three times during 2016: in February, June and October 2016. We found breaches of legal requirements at all three of these inspections which placed people at risk of unsafe and poor quality care. Medicines were not managed safely, risks to people had not always been adequately assessed and the provider’s systems for monitoring and improving the quality and safety of the service were not effective. Records were not always accurate and the provider had not always obtained consent from people or their representatives in line with the requirements of the Mental Capacity Act 2005 (MCA). We also found the provider did not have an effective system in place for recording and responding to complaints.

These concerns were so significant following the February 2016 inspection that we also imposed a condition on the provider's registration, restricting them from taking on any new service users without prior agreement from CQC. Following the June 2016 inspection we also took urgent enforcement action, placing a condition on the provider's registration, requiring them to submit medicines audits and any actions taken as a result of audit findings to CQC on a regular basis.

At this inspection on 27 February and 01 March 2017 we found the provider had made improvements in addressing the most significant concerns we had previously identified. The improvements made in the management of medicines meant we could remove the condition on the provider’s registration requiring them to submit medicines audits and any actions taken as a result of audit findings to CQC on a regular basis.

However we also identified continued breaches of regulations because records were not always accurate or complete. The provider’s systems for monitoring the quality and safety of the service had improved, but had not always identified issues or driven improvements. Insufficient action had been taken to ensure the service complied with the requirements of the Mental Capacity Act 2005 (MCA), although staff confirmed they only supported people with their consent and in their best interests in consultation with relatives.

We also found a breach of regulations because the provider had not sought and maintained a record of each staff members’ full employment history to help demonstrate that staff were of good character. We therefore decided not to remove the condition on the provider's registration, preventing them from taking on any new service users without prior agreement from the Commission.

Despite these issues, we found on-going improvements had been made in the majority of areas we reviewed in the time since our last inspection. Risks to people had been assessed and staff were aware of how to manage risks safely. People told us they received their medicines as prescribed, and the provider had implemented an effective process for receiving and addressing complaints.

There were sufficient staff deployed by the service to meet people’s needs and staff received safeguarding adults training. However improvement was required to ensure people were consistently protected from abuse because whilst most staff we spoke demonstrated a good understanding of safeguarding practices, two staff members were not aware of the different types of abuse that could occur.

People were supported by staff who had the skills and training to effectively meet their needs. They also received support to maintain a balanced diet where this was part of their care plan and were supported by staff to access healthcare services where required.

People and relatives told us they had been consulted about their care needs and were involved in day to day decisions about their care and treatment. They told us staff treated them with kindness and compassion, and respected their privacy. People had care plans in place which were reviewed periodically, in line with the provider’s policy, although improvement was required to the accuracy in the details of some people’s care planning.

Staff received regular supervision and an annual appraisal of their performance. They told us they felt well supported by senior staff and worked well as a team. People and relatives spoke positively about the attitude and management of the service. The provider sought the views of people through regular telephone monitoring checks and visits to people’s homes, and the outcome of this monitoring showed that people experienced positive outcomes from the care they received.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

We have inspected the service twice previously in 2016: in February 2016 and June 2016. We found breaches of legal requirements at both of these inspections, and people were placed at risk of unsafe and poor quality care. Medicines were not safely managed, risks to people had not always been adequately assessed and the provider did not have effective systems in place to monitor and manage areas of risk. Records were not always accurate and could not be promptly located. The provider did not have an effective system in place to monitor staff training needs, and the provider’s recruitment practices did not meet the requirements of the regulations. Notifications had not always been made. Our concerns were so significant following the February 2016 inspection that we also imposed a condition on the provider's registration, restricting them from taking on any new service users without prior agreement from the Commission. We also wrote to the provider asking them to take action to improve their recruitment practices and this action has been completed.

Following the June 2016 inspection we also took urgent enforcement action, placing a condition on the provider’s registration, requiring them to submit medicines audits and any actions taken as a result of audit findings to CQC on a regular basis.

At this inspection on 05, 06, 07 and 14 October 2016 we found that the provider had made improvements in some areas. However, we also identified continued breaches of regulations because people’s medicines were not managed safely. Records relating to people’s medicines administration were not always accurate or reflective of the medicines they had been prescribed. Audits of people’s medicines were not always effective in identifying and addressing issues. Risks to people had not always been adequately assessed and there was not always guidance in place for staff on how to manage risks to people safely. Some records were not always accurate or had not been properly completed. The provider had made improvements to the systems used to monitor and mitigate risks to people and we saw examples where this had driven improvements in people’s support planning. However, reviews of people’s care records had not always been prioritised safely and had not always addressed deficiencies in recorded information, placing people at risk.

We also identified breaches of regulations because the provider had not always obtained consent from people or their representatives in line with the requirements of the Mental Capacity Act 2005 (MCA), and because the provider did not have an effective system in place for consistently recording and responding to complaints.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

There were sufficient staff deployed within the service to safely meet people’s needs. The provider had appropriate recruitment processes in place but improvement was required to ensure that references received on behalf of new staff were consistently from robust sources. People were protected from the risk of abuse because staff were aware of the types of abuse that could occur and the action to take if they suspected abuse.

Staff were supported in their roles through training and regular supervision. They were aware of the importance of seeking consent from people when offering them support. People were supported to access healthcare services when required and were supported by staff to maintain a balanced diet where this was part of their assessed needs.

Staff treated people with kindness and consideration, and people told us their privacy and dignity were respected. People were involved in day to day decisions about their care and treatment, and received person centred care which met their individual needs. The provider had a complaints procedure in place and people told us they knew how to raise concerns.

The provider had systems in place to monitor the quality of the service provided and people told us they thought the service was well managed. Staff were aware of the responsibilities of their roles and told us the service was focused on providing good quality care to people.

The overall rating for this service is ‘Requires improvement’. However, the service will remain in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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.

Following the inspection we served warning notices on the provider and registered manager requiring them to comply with the regulations. Our concerns were so significant that we also imposed a condition on the provider’s registration, restricting them from taking on any new service users without prior agreement from the Commission.

We undertook this announced focused inspection on 23 June 2016 to check that the provider had met the requirements of the warning notices. At this inspection we looked at aspects of the key questions ‘Is the service safe?’, ‘Is the service effective?’ and ‘Is the service well-led?’ This report only covers our findings in relation to the focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Capital Homecare (UK) Limited’ on our website at www.cqc.org.uk.

Capital Homecare (UK) Limited is a domiciliary care provider located in the Royal Borough of Greenwich providing care and support to people across a number of London Boroughs. There was a registered manager in post at the time of our inspection. 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 this inspection we found that while a system had been implemented to monitor staff training and the provider had updated their whistle blowing policy, we identified continued breaches of legal requirements relating to safe care and treatment, monitoring the quality and safety of the service, and for failing to submit notifications as required.

Medicines were not safely managed because records relating to the management of people's medicines included conflicting information about the support they required and risks associated with specific medicines had not always been identified. Risks to people had not always been adequately assessed. There was not always sufficient guidance in place for staff on how to safely manage risks where they had been identified. The monitoring system used to ensure people received their visits as planned was not always effective and checks made on people’s care records had not always identified issues or driven improvement. Records were not always accurate and could not always be located promptly when requested. We also found evidence that the provider had failed to submit a notification relating to an allegation of abuse as required, despite these concerns being raised previously. CQC are currently considering the action to take to address these concerns.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

As a result of the findings of this inspection, we have reviewed the rating for the key question ‘Is the service well-led?’ which is now rated inadequate. This was because the provider had failed to make any significant progress in addressing the requirements of the warning notices we served following our inspection on 17 and 19 February 2016. The ratings for the other two key questions we looked at remain the same. The overall rating for the 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.

At our last inspection we identified breaches of regulations because the provider did not operate an effective safeguarding quality assurance process and because notifications relating to allegations of abuse had not always been submitted to the CQC as required. At this inspection we found that improvements had been made to the management of safeguarding concerns but the provider continued to be in breach of regulations because they had not always submitted notifications relating to abuse allegations. CQC is currently considering the appropriate regulatory response to address this continued breach in legal requirements. We will report on this at a later date.

Capital Homecare (UK) Limited is a domiciliary care agency located in the Royal Borough of Greenwich providing support for approximately 200 people across greater London. There was a registered manager in post at the time of our inspection. 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 this inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risks to people had not always been identified or properly assessed, and action had not always been taken to manage risks safely. Risk assessments did not always include areas of risk identified in local authority assessments received by the provider and action had not always been taken to mitigate risks where they had been identified. The provider did not have an effective rostering system in place to allocate calls to staff and this had resulted in missed visits. Medicines were not safely managed by the service because records relating to the management and administration of medicines were inaccurate and some records provided staff with conflicting information.

The provider did not operate effective systems to monitor and mitigate risks to people because audits of people’s care plans and risk assessments were not recorded and had failed to identify a range of concerns that we found during this inspection. Records relating to people’s care were not always easy to locate and could not be provided promptly when requested.

The provider’s whistle blowing policy did not provide any guidance for staff on how to report concerns to external agencies and one staff member told us they would only report concerns externally if given permission to do so by the agency. We also found that the system used to monitor staff training required updating as the information it contained was out of date. Therefore the provider could not assure us that they had an accurate overview of staff training needs at the time of our inspection. CQC is currently considering appropriate regulatory responses to address these breaches in legal requirements. We will report on this at a later date.

We also found a breach of regulations because the provider did not maintain a record of the pre-employment checks undertaken by the service prior to new staff starting work which included details of any gaps in their employment history. You can see the action we have asked the provider to take in respect of this breach of regulations at the back of this report.

There were sufficient staff available to meet people’s needs and staff were supported in their roles through training and regular supervision. People were protect from the risk of abuse because staff were aware of the action to take should they suspect abuse had occurred. Staff sought consent from people when providing them with support but improvements were required to ensure the provider worked within the requirements of the Mental Capacity Act 2005, should the service offer support to a person who lacked capacity to make specific decisions about their care and treatment.

People were supported to maintain a balanced diet and had access to healthcare professionals when required. They told us staff were caring and considerate, and that they were treated with dignity and respect. People were involved in making decisions about their care and treatment and told us that the support they received reflected their individual needs and preferences. However improvements were required to ensure people’s care planning was person centred and reflected their views.

The provider had a complaints procedure in place and people expressed confidence that any concerns they raised would be addressed to their satisfaction. People and staff told us that the service was well managed. The provider conducted regular spot checks on staff and undertook regular telephone surveys which showed people were happy with the service they received.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

Is the service safe?

Staff were aware of the importance of consent and people were asked for their consent before care was provided. People's needs were assessed and risk assessments were carried out before care was provided. These were regularly reviewed so that staff were aware of the best way to provide support.

The manager and other office staff including the business manager were available on a daily basis to respond to people's concerns or queries, and to monitor that people were being safely supported, for example in ensuring staff support was provided on time. There had been a number of concerns raised such as about some staff attendance, and these had been reported to local authorities and were investigated, and action taken to ensure continuity of care. Four of these cases were as yet not concluded when writing this report.

There were arrangements in place to deal with emergencies and to make sure people were safe. People's support needs, such as manual handling were included in their care planning to ensure that important health needs were met. The staff and manager were trained in protecting people from neglect or abuse and people told us they felt safe in their home.

Staff wore uniforms and carried photographic identification issued by the agency, to ensure that people who used the service were able to identify them and feel safe. All of the people we spoke with said that the staff always used these items.

All of the 60 people we spoke with who used the service said they felt safe in the way staff supported them. The majority said that staff were well trained and knew how to support them.

Is the service caring?

We spoke with 60 people who used the service or their families and people told us that the staff and supervisors were very caring and supportive. Many said staff always took the time to speak with them and spoke with them in a manner they understood. One person said 'they always say what they are going to do before they wash me', and a person's family said, 'they understand my relative's religious needs when they wash them and prepare their food.'

Care planning did not include enough specific information about how to support people as individuals, for example what they could do for themselves in order to maintain their independence.

Is the service effective?

We saw from 16 people's records we looked at that people's needs were assessed and a plan drawn up to meet those needs. People we spoke with told us they were happy with the plan provided. Regular reviews were made of the plan provided and people or their families told us they were involved in the reviews.

There were suitable policies in place for consent to care, assessing and planning care, safeguarding people, medication and quality assurance. The majority of the people we spoke with told us the staff knew how to support them well. People who used the service were consulted for their views on the service they received a regular basis, which involved the person, their family and social services. We saw that any changes they requested were included in a revised care plan.

Staff were provided with adequate support, guidance and training to do their job. They were experienced in supporting people with care needs such as dementia and continence management, and they told us that the training they received equipped them to support people with confidence.

Is the service responsive?

People we spoke with who used the service told us that the staff and manager always listen to their concerns and do something to help sort out any problems they are experiencing. People were asked for their views about their service and action was taken to address any problems, for example in changing a member of staff to one who communicated in the person's preferred language.

People's support plans were reviewed and changed when necessary in response to changing needs, for example in negotiating higher levels of support when necessary, or in changing the time of visits to accommodate people's personal preferences.

We were told that the carers were flexible and one person said, 'they went the extra mile' when supporting them.

Is the service well led?

There were some concerns raised by social services that the quality of safeguarding investigations needed to be improved and that the investigation information was passed on to them in a timely manner. All of the notifications regarding safeguarding incidents had not been reported to the Care Quality Commission as is required.

The registered manager was qualified and experienced and was involved in the day to day management of the service. There was an out of office hours on call system in operation to ensure that management support and advice was always available. There was a system for doing spot checks on staff working with people to monitor the quality and safety of care provided.

Comments received from people who used the service and families included, 'the supervisors are very good and regularly call in to see how the staff are doing', and 'I once had a problem with one staff and it was dealt with immediately'. Most of the people we spoke with reported being in contact with the agency monthly or more. One person said, 'the manager will always ask if there are any problems'. Phone monitoring helped to ensure that people received a good quality service.

Staff we spoke with told us that they felt the agency was very well managed and they received direction and training to help them to support people. Regular staff meetings and supervision sessions were held and staff said they felt able to raise any issues with the management openly and honestly, and felt the manager followed up on any issues quickly.