Head Office

Head Office is a supported living service providing personal care to people with a learning disability and/or autism. Some people also have physical disabilities and a mental health diagnosis. Support was provided across 21 different supported living settings where people had their own houses or rooms. As part of our inspection, we visited 11 of the supported living homes. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection 57 people were receiving a regulated activity.

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

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.

Right Support

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People were not being protected from abuse including financial, physical, emotional and verbal abuse. The risks associated with people’s care were not reviewed and updated to reflect the most up to date information. Staff were not always familiar with the risks around people’s care. Medicines were not always being managed in a safe way. There were not enough staff to support people safely. People were not always being treated in a kind and dignified way at all homes although we did see some caring interactions from some staff.

Right Care

Health care support was not always being sought for people and where it was, staff were not always following the guidance provided. Staff had not always received appropriate training and supervision to support people in the right way. People were not always being encouraged or given choices around healthy and nutritious meals. People and families were not always being involved in the reviews of care.

Right Culture

There was a lack of robust oversight of care by the provider. Where audits were being undertaken, they were not always picking up on shortfalls. Relatives and external professionals fed back concerns about the lack of actions and communication from the leadership team. Relatives did not always feel complaints would be responded to. Where feedback was sought actions were not always taken to make the improvements. The provider and leadership team were not encouraging an open culture within the staff team and were not always leading by example.

Rating at last inspection and update

The last rating for this service was good (published 16 January 2020).

Why we inspected

The inspection was prompted due to concerns received about people not being protected from abuse and unsafe care and unsafe staff levels. A decision was made for us to inspect and examine those risks.

We undertook an inspection to review the key questions of safe, effective, caring, responsive and well-led.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

Enforcement and Recommendations

At this inspection we have identified breaches in relation to people not being protected from the risk of abuse, people not being protected from unsafe care including risk mitigations and the management of medicines. We also identified breaches in relation to the failure to ensure the principles of the Mental Capacity Act were consistently followed, staff not being appropriately trained and supervised, and people not being supported appropriately with their health care needs. We also identified a breach relating to the lack of robust response to complaints, lack of person centred care and staff levels. We identified breaches relating to the lack of robust oversight by the provider and people not being treated in a caring and dignified way.

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 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

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

Mitchells Domiciliary Care Services is a supported living service providing personal care for people with a learning disability, autistic spectrum disorder or physical disability. At the time of this inspection the service was supporting 25 people across nine properties. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

Staff understood their safeguarding responsibilities and were confident if they raised concerns these would be fully acted upon. People told us they felt safe. Risks had been assessed and detailed plans to minimise these put in place. Staff told us they supported the same people to maintain consistency and did not feel rushed when providing care.

People received exceptional personalised care which met their needs and wishes. Care plans contained detailed information about how people wished to be supported. People were encouraged to set and achieve goals and fulfil their potential. Staff had received an outstanding award in June 2019 from a charity specialising in ketogenic dietary therapies. Staff had attended a course so they could learn more and understand the Keto diet to better support a person.

People were supported by caring and compassionate staff that sought to understand people’s backgrounds, current situations and future goals to ensure they delivered meaningful care.

Care plans demonstrated consideration for people’s culture and the differences in which people chose to live their lives.

Health action plans recorded good detail about people’s medical history, ongoing health and how they took responsibility over their own health care needs.

The agency was well led by the registered manager and their deputies who led by example. The provider promoted a positive and supportive culture that was person-centred, inclusive and empowering. Quality monitoring systems ensured that the care provided was reviewed regularly and improvements made where required.

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.

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

Rating at last inspection: The last rating for this service was Good (published 5 July 2017).

Why we inspected: This was a planned inspection based on the previous rating.

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.

Mitchells Domiciliary Care Services provides a supported living service for older people and people with a learning disability, autistic spectrum disorder, physical disability and younger adults. People receive personal care and support in their own properties. At the time of our inspection the service provided personal care to 22 people.

There was a registered manager in post and present at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager had systems in place which monitored health and safety and the quality of people’s support. However the systems were not always responsive and had not always led to changes being made. We have made recommendations around this. However people, relatives and staff were happy with the management support they received.

People told us they felt safe using the service. Relatives felt that their family members were safe with staff. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected. There were sufficient staff at the service to provide care and support to people. Appropriate recruitment checks were undertaken before staff started work.

Staff understood the risks to people and ensured that people were kept safe. Staff encouraged and supported people to lead their lives as independently as possible. People’s medicines were managed in a safe way and staff were competency assessed to ensure that they were competent in the administration of medicines.

People received support from staff that knew them well, and who had the knowledge and skills to meet their needs. Training was provided to staff that was specific to the needs of people including challenging behaviour and epilepsy. Staff received supervision to provide effective care to people and staff felt supported.

People had care plans in place which provided guidance for staff about how people liked their care provided. People and relatives were involved in the care planning.

Staff understood the Mental Capacity Act 2005 and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. Relatives were involved in making decisions where appropriate. Where people were being deprived of their liberty this was done in their best interest.

Staff supported people with their nutritional and hydration needs. Health care professionals were involved in people’s care and staff ensured that they followed guidance provided by them.

Complaints and concerns were taken seriously and used as an opportunity to improve the service. People and relatives said they knew how to make a complaint if they needed to.

The registered manager had informed the CQC of significant events. Records were accurate, well maintained and kept securely.

The inspection was announced. We told the provider three days before our visit that we would be coming. This was to ensure that the people we needed to talk to would be available.

There was a registered manager in place who was present on the day of the 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.

Effective systems were not always in place to monitor the quality of the service that people received. Audits were not routinely undertaken and surveys were not always used to improve the quality of care.

Complaints were not always responded to in an appropriate way.

People did not always feel involved in their care planning. Relatives also said that they did not always feel consulted however other relatives said that they were.

Care plans and records were not written in a dignified and respectful way. However people did say that staff treated them with dignity and respect. Relatives confirmed this. People’s independence was promoted. In the event of an emergency, such as bad weather, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

There were sufficient numbers of skilled and experienced staff to support the people who used the service. People and their relatives told us they were supported by regular staff who knew their needs and preferences well.

Training was provided to staff in relation to the needs of people who received care. Staff had their competencies assessed through regular one to one supervisions and appraisals.

People were cared for by kind, respectful staff. People told us they looked forward to staff coming to support them.

Systems were in place to ensure that people were protected from the risk of abuse. Staff were aware of procedures to follow to safeguard people from abuse. Risk assessments were detailed and staff were provided with guidance on to reduce the risk of things happening. There were assurances that before staff started work appropriate recruitment checks had been undertaken on all care staff however not all administrative staff who came into contact with people had undergone these checks.

People were supported at mealtimes to have food and drink of their choice and supported to make healthy choices about their food. People were supported to have access to health care as they needed it.

People’s right were being upheld as required by the Mental Capacity Act (MCA) 2005. This is a law that provides a framework to protect people who do not have mental capacity to give their consent or make certain decisions for themselves. Staff were aware of their responsibilities through appropriate training in regards to the Mental Capacity Act 2005.

Medicines were safely administered and people received their medicines in the way that had been prescribed for them. Each care file had clear instructions to care staff stating whether the person was to be administered medication as part of the care plan.

The registered manager had ensured that the Care Quality Commission (CQC) were informed of important events that happened in the service.

During our inspection we found a number breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have also made recommendations in relation to regulations.

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

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

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe with

the staff. One person who was a regular visitor to a person who uses the service told us they visited on several occasions during the day and had never witnessed poor practice from the staff.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The provider reported safeguarding alerts to the local authority and notified CQC. This reduced the risks to people and helped the service to continually improve.

The registered manager sets the staff rotas, they take people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people's needs were always met.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Relatives that we spoke with confirmed they had been involved in the care planning when their relative were first started to receive care from the service. They also told us that the reviews held by the service reflected their current needs. Relatives that we spoke with confirmed that although they were not always informed formally when the care plans changed staff always spoke to them and would notify them immediately of any changes.

Is the service caring?

People told us that they were supported by kind and attentive staff.

Comments received from relatives included "Staff are kind and caring and were always willing to go a bit more to help'.

"When my family members health deteriorated it was the staff who spent a long time

sitting and encouraging them to eat and drink to avoid a hospital admission".

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People told us they knew how to make a complaint if they were unhappy. We looked at the complaints record and found there had been no complaints made to the provider. We were told that the complaints policy was displayed at the various locations where the service provided care. The complaints policy we looked at had been designed, written and developed to be user friendly in an easy read pictorial format. Relatives confirmed that they had not needed to make a complaint. People could be assured that if a complaint had been received there was a system in place which would ensure investigation and action.

Is the service well-led?

The service worked well with the local authorities that had placed people with the domiciliary care agency. This ensured people received their care in a joined up way.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the service and that quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We undertook a random telephone survey of the people who used the service. Three of these calls included talking to the person's relative.

People who used the service told us that they were treated with respect by the staff. They told us that staff always respected their privacy and dignity. One person told us, "Staff always make sure that my doors are closed and curtains pulled when they help to wash

me." Another person told us, "The staff were very pleasant and they always respect me." People also told us that they made decisions about their care, treatment and support, for example, one person told us, "I can ask for things to be done differently and staff would do

it." Another person told us, "Staff let me do as much as I can for myself, I like to be independent."

People told us that they had an assessment of their needs undertaken and they had a care plan at their homes. They told us that they always felt safe with the staff who attended to them. People also told us that a member of staff from the office comes to do spot

checks to make sure the staff were confidently carrying out their duties.

Relatives we spoke to told us that they were involved in the assessment and care planning process and they knew how to raise concerns and make complaints about the service their relative received.

We were told by the people who used the service and their relatives they had just completed a Quality Questionnaire about the how they felt about Mitchells Domicilliary Care.