Fortress Care Services

Fortress Care Services is a domiciliary care agency which provides personal care and support to adults in their own homes. At the time of our inspection the service provided personal care to one person. One live-in care worker provided most of the person’s care. Their breaks were covered by the care co-ordinator.

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

The provider and registered manager did not demonstrate they had learned from previous inspections or had applied learning across the service. They had still not taken enough action to make, or sustain, required improvements identified at previous inspections. They had not always taken the action they said they would take regarding safe administration of medicines, guidance for staff on how to meet all of the person’s needs, and governance.

Staff were trained to administer medicines and their competency was assessed. This helped to ensure the person received their medicines as prescribed. Staff knew the person well. However, the guidance did not provide any guidance for staff on how to recognise if the person may be in pain. This meant any new staff may not know when to offer pain relief. Shortfalls in staff guidance for medicines prescribed “when required” had been highlighted at our previous inspection.

Records did not always provide consistent or complete guidance in how to meet the person’s needs. A live-in care worker provided the person’s care most of the time and knew the person extremely well. Their breaks were covered by a relief member of staff who also knew the person well. However, there was not sufficient guidance to ensure all the person’s needs would be met should new staff provide their care.

Risks had been assessed in relation to the person’s care. However, risks for staff, which could impact on the care the person received, had not always been formally assessed. These included the main care worker working for long periods of time without a break.

The provider and registered manager did not demonstrate they could implement new government guidance. For example, they had not implemented a system for staff to be tested for COVID-19 in line with current good practice guidance.

The provider had not employed any new staff since the last inspection. This meant we were unable to test their recruitment and induction processes.

Staff members had received training relevant to their roles. Staff felt well supported by the management team and received regular supervision and appraisal.

The person was supported to have maximum choice and control of their life 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.

Staff supported the person to maintain a healthy diet and to access healthcare services when needed. They liaised with health and social care professionals and followed their instructions.

Care staff were very caring and the relative was happy with the care their family member received. Care staff supported the person to maintain contact with people important to them.

The relative knew how to complain and was confident any concerns they raised would be addressed within the service. No complaints had been made since the last inspection.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 31 December 2019). There were two breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made or sustained and the provider was still in breach of regulation 17.

The service was rated requires improvement overall at the last two inspections and inadequate overall at the two inspections before that.

Why we inspected

We carried out an announced comprehensive inspection of this service from 30 September to 2 October 2019. We found two breaches of legal requirements. The provider completed an action plan after the last inspection to show what they would do and by when to improve the safety and good governance of the service.

We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continued breach in relation of the governance and management of the service at this inspection.

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.

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.

Fortress Care Service is a domiciliary care agency which provides personal care and support to people in their own houses and flats in the community. It can provide a service to older and younger adults, who may be living with dementia or have a disability. At the time of our inspection the service was providing personal care to two people and occasional respite personal care to one other person.

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.

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

People’s experience of using this service:

Previous inspections of this service have highlighted serious failings on the part of the provider. We rated the services as Inadequate at two previous inspections in 2017 and 2018 and it was placed into special measures. At our last inspection we found that some improvements had been made and the rating improved to Requires Improvement and the service was taken out of special measures. At each of the last three inspections we found issues relating to leadership and the management of risk. At this inspection we had continued concerns. Systems to ensure people received safe care which met their needs were still not robust.

We had concerns about how some risks were managed. Systems to ensure that people took their medicines safely, and as prescribed, were not robust. The provider did not monitor how medicines were managed by staff. Information about people’s medicines was not comprehensive. This placed people at potential risk of harm.

The provider had not thoroughly assessed and documented people’s risks. The provider had tried, in some cases, to respond to people’s individual needs but had not considered all the possible implications in terms of people’s safety.

The initial assessment of private clients, who did not come with their own county council assessment already in place, was not sufficiently robust. We were not confident that the provider would carry out a comprehensive assessment of any new client’s care.

The provider did not have proper oversight of the care provided. Audits failed to identify concerns found on inspection. Some key members of staff were skilled and demonstrated a commitment to providing good care. However, the provider’s procedures did not ensure that this care would be consistent should these key staff not be on duty. Staff were found to keep records and operate local systems of work which the provider did not have oversight of.

Care records documented that people had consented to their care plan. Staff at all levels needed a better understanding of capacity and consent. We have made a recommendation relating to this.

Care records captured people’s individual daily routines very well and documented their preferences. However, some key information was missing from care plans and they did not always reflect people’s most current needs.

Staff were safely recruited and were provided with training to help them carry out their roles. The provider carried out spot checks to make sure staff were following best practice. Staff understood their responsibility to keep people safe from abuse and knew what action to take if they suspected abuse was taking place.

People were very positive about the kindness and reliability of the staff. Established staff knew people's needs very well. Relationships were close and caring. A lack of information in care records meant that there was a risk that newer or bank staff would not be able to support and care for people e well.

Staff demonstrated a good understanding of people’s healthcare needs and of the support they needed with eating and drinking.

There had been no complaints and a clear policy and procedure was in place. The provider consulted people who used the service about their care and tried to respond to their suggestions and requests.

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

Rating at last inspection

The last rating for this service was requires improvement (published 24 September 2018) and there were two breaches of regulation. The provider completed and action plan and was required to complete a monthly update to show what improvements they had made and planned to make in the month ahead. Sometimes the provider failed to provide this monthly update. At this inspection we found that the required improvements had not been made and the service remained in breach of the same regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches of regulation in relation to the management of risk, the management of medicines and leadership at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will continue to do to improve the standards of quality and safety. We will meet with the provider to discuss how they can bring about the required improvements. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner

We last inspected the service on 8 and 9 February 2018 and 2 March 2018. At that inspection we rated the service as Inadequate and we identified seven breaches of regulation relating to safety, staffing, recruitment of staff, person centred care, complaints, displaying the rating and overall leadership. The service remained in special measures having been previously placed into special measures after the inspection carried out in August 2017. When a service is placed in special measures the expectation is that providers found to have been providing inadequate care should have made significant improvements by the time we carry out our next inspection. Following the August 2017 inspection we also placed conditions on the provider’s registration which were designed to ensure people who used the service were safe. The provider remains bound by these conditions and is not free to taken on any new care packages without the permission of the Care Quality Commission (CQC).

Fortress Care Services is a domiciliary care agency. It provides personal care to people living in their own homes. It provides people with both daily care visits and also live-in care. At the time of our inspection five people were using the service.

The service had a registered manager in post but day to day leadership of the service was provided by the nominated individual of the business due to the registered manager’s continued ill health. 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.

It was clear to us at this inspection that the provider had worked hard on certain areas of the business and we found some significant improvements. We also found that, as with previous inspections, in the majority of cases people received good quality care from regular carers who knew them well. We did however identify concerns around people’s safety, the management of risk and the promptness of the response to incidents and safeguarding matters. These areas continue to need further improvement and we have identified a continued breach of regulation relating to the safety of the service.

We noted a positive change in the way staff were safely recruited, inducted, trained and supported. Staff all received training in core subjects from a recognised training provider. This equipped them to carry out their roles and some had additional training. All staff felt supported and good systems were in place to provide supervision and support, although one staff member was not well supported in managing care for one particular person.

Staff received training in safeguarding people from the risk of abuse. The provider had raised no safeguarding concerns since our last inspection. However, they had not acted promptly to refer someone, who may have been at risk of neglect. The provider had tried to raise the concern but they, and the staff on duty, had not acted promptly and effectively which left the person at further potential risk.

Risks to people’s health and safety were assessed and managed but some information was not accurate which could give staff a confusing picture. This was especially the case related to one person’s risk of falls. Information about risk was confusing and new staff would not have all the information they needed to protect people. Other risks were better managed but we did identify that storage of one person’s medication may have placed them at risk. The provider took prompt action when we raised this issue and reduced the risk.

Medicines were administered by trained staff and their competence to do this was checked. A lack of robust stocktaking measures meant we could not be assured that people always received their medicines correctly. The provider did not carry out a robust audit of medication records and did not have sufficient oversight of the safety of medicines at the service. However they introduced a new audit system in response to our feedback and put it in place immediately.

Staff who supported people regularly, demonstrated a very good understanding of people’s needs and there was now a clear strategy for covering staff absence, including that at short notice.

The provider carried out an assessment of people’s needs and encouraged people to be involved in decisions about their care and support. Care plans were comprehensive and were designed to be person centred. However, some information was not accurate and had not been promptly updated after a change in circumstance. This meant there was a risk that people would not receive care and support which met their individual needs. Regular staff knew people’s needs well.

Staff supported people to manage their healthcare needs and access the care they needed. Care plans did not always clearly record the involvement of other healthcare professionals and some key information had been archived. This was an issue at our previous inspection.

People received good support related to their eating and drinking, although guidance for staff could be clearer. Staff worked with other healthcare professionals to support people’s eating and drinking but records had been archived and so their advice and guidance was not clear. People’s preferences with regard to their eating and drinking were respected.

People or, where appropriate, their relatives, consented to their care and their choices were respected. Staff had received training in the Mental Capacity Act 2005 (MCA). The MCA ensures that people’s capacity to consent to their care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. There remained some confusion in records with regard to consent to care and treatment but it was clear that people, or their relatives if appropriate, were being asked.

Staff treated people with patience and kindness and relationships were good. Staff respected people’s privacy and maintained their dignity and people were happy with the way staff treated them. Staff promoted and maintained people’s independence which enhanced their dignity and self-esteem.

A complaints procedure was in place, but no formal complaints had been received. People felt able to raise issues with staff or with the provider. Information about how to complain was available.

There was a system of audits and spot checks in place to monitor the safety and quality of the service. Spot checks were good and supervision of staff, especially live-in staff, had improved considerably.

The provider did not fully understand all their responsibilities with regard to the regulation of the service. They had not notified CQC of some relevant matters regarding the health and welfare of people who used the service. However the rating from our previous inspection was now clearly displayed on the service’s website.

Previously we had found that the provider was not always open, honest and transparent with us. Sometimes we had identified concerns and key information by chance when looking at other matters. We found this was not the case at this inspection and the nominated individual and the registered manager were both keen to work with us and were honest about the further work they needed to do to continue driving improvement at the service.

We recognize that the provider has made some clear improvements since the last inspection and we welcome these. We are encouraged that regular carers are providing a good service to people although we remain concerned that some practice is continuing to place people at risk. We are not yet fully assured that the provider understands all their responsibilities and are not confident in their ability to be proactive in the management and oversight of risk. We would have expected there to be no areas for further improvement after such a long time. However, we recognise the hard work which has gone into making the improvements we did find and expect this to be sustained.

Fortress Care services is a service that provides personal care to people in their own homes. At the time of the inspection nine people were receiving support from the service.

There was a registered manager in place. They were also the owner and director of the business. 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 and associated Regulations about how the service is run. At the time of our inspection the registered manager was on long term leave and we did not speak with them. The business was being run by their partner, who was also the owner and nominated individual of the business, which meant they had a legal responsibility for the service.

At our last inspection on 23 April 2015 we rated the service as Good. This scheduled inspection was arranged to assess the quality of care currently being delivered and to address some concerns which had been raised with us.

At this inspection we had serious concerns about the quality and safety of the service.

The service failed to provide consistently safe care. People were not protected from the risk of abuse as the provider failed to operate a robust recruitment procedure. Required checks to make sure staff were safe and legal to work at the service had not been carried out thoroughly. Staff, who were the subject of a current safeguarding investigation were working unsupervised without the risk being assessed and action taken to mitigate it.

Accidents and incidents were not well managed and the provider failed to notify the appropriate authorities or to carry out investigations when people’s safety had been placed at risk.

There was no effective staffing strategy in place to cover emergencies and staff annual leave. This meant that people received inconsistent care or did not receive the care they needed.

Medicines were managed safely and people received their medicines according to the prescriber’s instructions.

Staff training, including medicines training, was in place but the provider could not supply accurate records to confirm when staff had received their training. Staff had not had some specific training, such as training for particular health conditions.

Records did not demonstrate that people had consented to their care. The service was not operating in line with the Mental Capacity Act 2005 (MCA).The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process.

People were supported with their eating and drinking and were positive about this aspect of their care. Healthcare needs were mostly met but records for some people, who had 24 hour live-in care packages, did not show that their health needs were well monitored by other health professionals such as dentists and opticians.

Staff were mostly very caring and held in very high regard by people who used the service. People felt their dignity and privacy was maintained. Feedback about some staff’s disrespectful language and behaviour was negative.

People did not receive care which reflected their individual needs and preferences. Some care was delivered according to the availability of staff rather than the preferences of the person who used the service.

People were not clear about how they should make a complaint. Some people who used the service, and their relatives, had significant and serious complaints and we were not clear why they had not felt able to raise these with the provider.

Ultimately the service was not well-led. Despite some good and committed staff we found that people did not always receive safe and timely care which met their needs and was delivered according to their preferences. The lack of an effective staffing strategy meant that annual leave was not always covered by staff who knew people’s needs well. Some care visits were missed which meant one person had to find alternative care arrangements for a period of three days.

The provider was not honest, open and transparent during the inspection process. They failed to supply us with information we requested and did not tell us the most basic information, such as how many people used the service. This meant it was difficult for us to accurately assess the service and the impact it had on people.

The provider’s poor recruitment procedures and disregard for safeguarding procedures placed people at risk. On safeguarding matters the provider prioritised staff needs over those of the people who used the service.

Governance systems did not ensure that the provider had oversight of the issues affecting the service or of forward planning. This placed people at risk.

We identified several breaches of regulation during this inspection.

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.

We last inspected the service on 8, 9, 23 and 25 August 2017. We rated the service Inadequate overall and identified multiple breaches of regulation relating to safeguarding, the recruitment, skills and availability of staff, leadership, consent, person centred care and the management of complaints and of risk. The provider had also failed to notify the Care Quality Commission (CQC) about the absence of the registered manager from the service.

Following the inspection we placed the service into special measures. When a service is placed in special measures the expectation is that providers found to have been providing inadequate care should have made significant improvements by the time we carry out our next inspection. At this inspection we found that the service had not made sufficient progress in the intervening months. We were still not assured that people would always receive a consistently safe and high quality service which met their individual needs.

Fortress Care Services is a domiciliary care agency. It provides personal care to people living in their own homes. It provides people with both daily care visits and also live-in care. At the time of our inspection six people were using the service.

The service had a registered manager in post but leadership of the service was provided by the nominated individual of the business. 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.

Staff received training in safeguarding people from the risk of abuse. The provider had raised no safeguarding concerns since our last inspection but had not acted promptly to refer someone, who may have posed a risk to people who used the service, to the Disclosure and Barring Service (DBS). This demonstrated a failure to take all possible actions to protect people from the risk of harm.

Risks to people’s health and safety were poorly assessed and managed, especially related to people’s risk of falls. Information about risk was confusing and new staff would not have all the information they needed to protect people.

Staff who supported people regularly demonstrated a good understanding of people’s needs but there was a lack of a clear strategy for covering staff absence, especially that at short notice.

No new staff had been recruited since our last inspection but those already in post and those who had transferred from the provider’s recruitment agency had not all been safely recruited. Records did not clearly demonstrate that all staff had the required DBS checks in place before they took up their post and two references had not always been sourced. This meant the provider was not acting in accordance with their own recruitment policy.

Medicines were administered by trained staff but a lack of stocktaking measures meant we could not be assured that people always received their medicines correctly. The provider did not carry out a robust audit of medication records or staff competence to administer medicines. The provider did not have sufficient oversight of the safety of medicines at the service.

The provider carried out an assessment of people’s needs and encouraged people to be involved in decisions about their care and support. Assessments were not always accurate and contained contradictory information, or had important information missing, which could place people at risk.

Staff received training to carry out their roles and training provision had improved since our last inspection. However we remained concerned about the quality of the training and induction for new staff and the provider’s oversight in this area.

Staff supported people to manage their healthcare needs and access the care they needed. Some staff demonstrated a lack of understanding of people’s specific healthcare needs. Care plans did not clearly record the involvement of other healthcare professionals and some key information had been archived.

People received good support related to their eating and drinking.

People or, where appropriate, their relatives, consented to their care and their choices were respected. Staff had received training in the Mental Capacity Act 2005 (MCA). The MCA ensures that people’s capacity to consent to their care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process.

Staff mostly treated people with patience and kindness and relationships were good. Action was not always taken to reduce one person’s distress. Staff respected people’s privacy and mostly maintained their dignity but some people were observed to appear unkempt which did not ensure their dignity.

Care plans were comprehensive and were designed to be person centred. However, some information was not accurate and some plans were not complete. This meant there was a risk that people would not receive care and support which met their individual needs, especially if staff were new or had not worked with them before.

A complaints procedure was in place, but a formal complaint from a healthcare professional had not been investigated. People who used the service did not all know how to make a complaint although people felt comfortable raising any informal issues with the provider.

There was no structured system of audits in place to monitor the safety and quality of the service. Spot checks were not thorough and supervision of staff, especially live-in staff, was very infrequent.

The provider did not fully understand all their responsibilities with regard to the regulation of the service. They had not notified CQC of important incidents affecting the health and welfare of people who used the service. They also failed to display their previous Inadequate rating on their website. This had the potential to mislead people.

The provider was not always open, honest and transparent. Sometimes we identified concerns and key information by chance when looking at other matters. This did not demonstrate a proactive approach on the part of the provider to work with CQC to bring about the all the required improvements at this service.

We recognize that the provider had made some improvements since the last inspection and we welcome these. We are encouraged that some individual carers are providing a good service to some people. However this inspection has found that many concerns remain and some new concerns have been identified. We do not feel that the service has made the improvements expected in the months since our last inspection. This service will remain in special measures and CQC intends to take further action to ensure people always receive consistently safe and high quality care.

As part of this inspection we spoke with one person who used the service and two people's relatives. We also spoke with the provider's representative and two members of staff. We reviewed records relating to the management of the service which included four care plans, daily records, staff records and quality assurance monitoring records.

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Risk assessments for people's care needs were available but had not been completed with enough information to identify the specific risks to each person or how they should be reduced.

Information was available in people's care records to provide guidance to staff members regarding which health care professionals the person visited or had involvement with. However, there was no other information in care records to guide staff about people's health needs.

Medicine administration records were not maintained and care plans did not show that people received their medicines in a safe way.

Not all of the required recruitment checks had been obtained or completed to an acceptable standard to ensure new staff members were safe to work with vulnerable people.

Is the service effective?

People told us that staff members helped them with everything they needed assistance with.

Staff members received supervision and basic induction training from the provider's representative or from the manager. However, competency checks were not completed for all staff to ensure they had the skills to properly carry out their roles and care for people.

Is the service caring?

People said that staff members were polite and kind; they respected people's privacy and dignity, and involved them in their care. Staff members knew people's care needs and their personal preferences when we spoke with them.

Is the service responsive?

We saw that people's individual physical Support and care needs were not properly planned for. There was little information about their individual choices and preferences regarding their support and care in care records.

Is the service well led?

There were inadequate systems in place to gather people's or staff members' views about the quality of the service. Other systems were not in place to monitor and assess the quality of the service provided and none of the issues found at this inspection had been identified by the provider.