Archived: HF Trust - Devon DCA

HF Trust – Devon DCA is a supported living service providing personal care to 28 people at the time of the inspection. HF Trust – Devon DCA is part of a larger national provider for people with learning disabilities (HF Trust) and is registered to provide personal care to people living in the community.

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 lived in shared houses and bungalows in residential areas in south Devon.

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

People were safe. Care had been taken to recruit the right staff, and to make sure there were enough staff available when people needed support. In the last year the number of permanently employed staff had increased and the use of agency staff to cover vacant shifts had significantly decreased. This had resulted in people being supported by staff they knew well, and staff they liked and trusted. New staff had received good training and support at the start of their employment. Staff received ongoing training and regular updates on topics relevant to the needs of the people they supported.

Since the last inspection the support plans had been improved. Risk assessments were carried out on all anticipated risks. Support plans gave clear instructions to staff on all aspects of the support people wanted. People had been involved and consulted in drawing up and reviewing their support plans. They were offered a copy of their support plan in a format they could understand, for example, some people had a support plan containing photographs and pictures. People were supported to hold and manage their medicines safely.

People led healthy lives. Staff understood each person’s health needs and supported people to obtain medical treatment promptly when needed, attend appointments and receive regular check-ups and treatment. People were able to choose the meals they wanted to eat and supported to plan menus, shop for ingredients, and prepare their own meals as far as they were able.

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.

People were supported by staff who were cheerful, positive and caring. People who were able to express their views verbally told us they were very happy with the support they received from the staff. One person told us, “They are all very friendly. They are all very supportive to us.” Another person gave us the ‘thumbs up’ sign when we asked them if they liked the staff. Staff were passionate about giving people the right support to help them gain independence and to lead fulfilling and happy lives. People lead active lives, doing things they enjoyed, for example attending clubs, going on outings and holidays, and participating in activities such as swimming, arts and crafts.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

People were involved and consulted in all areas of the service. They were supported to raise ideas, voice concerns, and make complaints. Their views were sought in various ways including questionnaires, house meetings and through local and national forums. The provider listened and took action on their comments and ideas.

The service was well-led. At the time of this inspection there was no registered manager in post. Two senior members of staff were jointly sharing the role of acting manager while the provider was in the process of recruiting and appointing a new registered manager. The regional manager was based in the local area and was actively involved in the management of the service. Staff told us the service had continued to be well-led under the two acting managers. Comments included, “Communication has been brilliant between staff and managers” and “Improvements in the last year have been exciting. It no longer feels as if we are 'fire-fighting'. Staff morale is much better, staff are much happier. We are all working towards the same goals now.” The provider had systems in place to monitor the service and make improvements where needed.

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 29 June 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.

This inspection was announced and took place on 26 April and 2 May 2017.

The service had 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.

We previously undertook a comprehensive inspection of the service in April 2016 when we rated the service as ‘good’ overall with the question of ‘well-led’ rated as requires improvement. In December 2016 we undertook a focused inspection in response to concerns raised with us about people not receiving safe care and treatment and the staffing arrangements within the service. We rated the key question of ‘safe’ as requires improvement. We identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the inspection in December 2016 the service sent us a plan describing the actions they had taken to improve.

At this inspection, in April and May 2017, we found improvements had been made to staffing arrangements and how the service was managed. However, while people were receiving safe care and support, some improvements were required to ensure risk management plans accurately reflected the action staff were taking to keep people safe.

Risks to people’s health, safety and welfare had been assessed and the outcome recorded in their care files. Management plans had been developed to identify how to support each person in a way that minimised these risks. However, we found some management plans did not include all the actions staff were taking to keep people safe. For example, one person’s risk management plan did not identify that staff must supervise them at all times when they were in the communal areas. The registered manager gave assurances these plans would be amended immediately.

People received support from staff who had been safely recruited and well trained. Changes had been made to the number of people the service could support. This had resulted in improved staffing arrangements and the service was less reliant upon agency staff. Staff were aware of their responsibilities to protect people from abuse. The service provided people with guidance and information about protecting themselves when in the community.

Some of the people receiving support could become anxious and display behaviours that may put themselves or others at risk. Hft had a team of advisors who supported staff in assessing people’s needs and provided guidance to promote people’s positive behaviour. Staff told us they had completed training in supporting people who may display potentially aggressive behaviour and were familiar with appropriate distraction techniques.

People’s medicines were managed safely and they received their medicines as prescribed by their doctor. Medicines were stored securely and only staff trained and assessed as competent administered medicines. Senior staff undertook weekly audits of medicines in each supported home. This ensured medicines were ordered when needed, given as prescribed and records were properly completed. People were referred to health care services when necessary. These included GP or community nurses as well as more specialist services such as hospital consultants and physiotherapists. Staff monitored people’s health conditions and liaised with healthcare services as necessary.

Some of the people we spoke with were able to share their views with us. They told us they liked their homes, the people they lived with and where they lived. For those people who were unable to express their views verbally, we saw them approaching staff with confidence and accepting appropriate prompts from the staff indicating they felt safe in their presence. Staff spoke with people in a polite and friendly manner and we saw people and staff sharing jokes.

During the inspection we spoke with or received emails from four relatives, one of who said staff had not been attentive enough to their relative’s needs. They said they had met with the registered manager to explore this. The registered manager confirmed that in response to the relative’s concerns changes had been made to the person’s support plan to ensure staff were provided with more detailed guidance about this person’s needs. Other relatives provided positive feedback to us. One said their relative had a “happy and enjoyable life” and “a lovely relationship” with their staff team. They also said “It's clear that they have [name’s] well-being and happiness at heart.”

People had their needs reviewed on a regular basis with staff who knew them well. People were encouraged to plan activities for enjoyment and for developing their independent living skills. Staff told us they supported people to be as independent as possible and described the technology used to help people with this. For example, one person used an electronic medicine cassette and another a “talking” book. People were supported to maintain relationships with people important to them such as their families and friends. People were provided with easy to read information about their rights to be treated with dignity and respect with regard to relationships, decision making and lifestyle choices. The service continued to run a monthly 'Voices to be Heard' meeting for people to be involved in and share their views. These meetings formed part of Hft's national 'Voices to be Heard' process to involve the people they support to advise on how the service should be run and how people should supported. People had access to the complaints procedure. This was also available in an easier to read format with pictures and symbols to help people read it. People confirmed if they were unhappy they would tell the staff. For those people who were not able to communicate verbally, staff told us they would look for facial expressions and changes in behaviour to tell if a person was unhappy. The registered manager confirmed that people had access to a local advocacy support group should they need independent advice and guidance.

Staff received regular training in the Mental Capacity Act 2005 (MCA). Protecting people’s rights to make decisions was instilled throughout all of the training provided for staff. People were supported to make choices about their care and their preferences were always considered and respected when planning their support. Some people were having their liberty restricted either to keep them safe or as a result of the staffing arrangements commissioned by the local authority. The registered manager was in consultation with the local authority to review these arrangements.

The registered manager and staff said the changes made to the management structure had led to a more consistent approach to managing the service. The registered manager had reviewed the requirements of the service and identified three key senior staff to support them in their role. These senior staff had clearly defined responsibilities for rota planning, support plan reviews and staff supervisions and observations of their work performance. One senior staff member told us, “We’re a close management team” and said their communication with the registered manager was “excellent.” Relatives told us they felt the service was being well managed. One said, “[name] is an excellent manager. We are able to be open and frank and feel totally supported by her. She is proactive and very able.”

Since the inspection in December 2016, the registered manager had been working with the local authority’s Quality Assurance and Improvement Team (QAIT) to review the service’s arrangements to audit its quality and performance. As a result the registered manager had developed a comprehensive plan of internal audits. They visited each supported home every week and communicated actions as a result of these visits and audits to the staff team. A service improvement plan was in place which was updated as actions were identified and taken.

We made a recommendation to the service to review each person’s risk management plans to ensure they accurately reflected the actions being taken by staff to keep them safe.

This unannounced focused inspection took place on 6 December 2016. It was undertaken in response to concerns raised with us about people not receiving safe care and treatment, and the staffing arrangements within the service.

The service was previously inspected in April 2016 when it received an overall rating of good, with the key question of well-led rated as requires improvement in relation to how the service was managed.

Since that inspection there had been changes to the management structure within the service. In April 2016 there were two registered managers in post, each with a responsibility for a geographical area. At the time of this inspection in December 2016, the service had one registered manager with the responsibility for both geographical areas. 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 the high use of agency staff unfamiliar with people’s care needs had led to some people being placed at risk of not receiving safe care. Some people were also reluctant to receive assistance from staff they did not know well and people were not always supported by their preferred gender of staff.

We made a recommendation that the service keeps its staffing arrangements under review.

Although staff had access to people’s care records, these did not always provide an accurate account of each person’s support needs. Daily care and monitoring records were incomplete and it was not always possible to ascertain the care and support provided to people.

The service’s management team had taken steps to improve the consistency within the staff team. They were aware of the need to improve the support and were working closely with the local authority’s quality assurance and improvement team.

We found the service was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the service to take at the end of this report.

This inspection was announced and took place on 4, 6, 7 and 8 April 2016. We gave 48 hours’ notice of the inspection because HF Trust – Devon DCA provided a supported living service for people who are often out during the day. We needed to be sure the registered managers and some of the staff and people receiving support from HF Trust would be available for us to speak with.

There were two registered managers in post, each with the responsibility for a geographical area or cluster. 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.

Prior to and following the inspection we had received concerns about how the service was managed and how the quality of the support provided was reviewed and monitored. Issues related to how medicines were managed; how people were being supported to promote their independence; how staffing was arranged, and the use of, and the quality of the information proved to agency staff.

At this inspection we found the regional manager was aware of these issues and they had been working with their own internal quality assurance team as well as the local authority’s quality and improvement team to address these concerns. The regional manager had developed an action plan and changes had been made to the service’s practices as a result. Audits of how medicines were being managed at each person’s home were now being completed, agency staff had better access to information about people’s support needs and there was greater management presence to support staff.

Those people who were able to share their views with us told us they liked their home and felt safe there. For those people who were unable to express their views verbally, we saw them approaching staff with confidence and accepting appropriate prompts from the staff indicating they felt safe in their presence. Staff recruitment practices were safe and people were involved in staff recruitment and reviewing staff suitability throughout their probation period. A comprehensive training programme ensured staff had the skills and knowledge to meet people’s needs. Risks of abuse to people were minimised because staff had received training in recognising and reporting abuse and they felt confident both registered managers would respond and take appropriate action if they raised concerns.

Not everyone we spoke with was able to tell us about their relationship with the staff who supported them. Those who could told us they liked the staff and the staff were nice. For those people who could not tell us, we saw them spending time with staff, sitting next to them and smiling as they freely approached them. This indicated people had a good relationship with the staff. The staff talked about people with affection and some staff became emotional when talking to us about how much they enjoyed their work. Staff described themselves as “enablers” rather than “carers” as they felt their role was to support people to live as independently as possible and to learn new skills. Throughout our inspection we saw examples of a caring and kind approach from staff who knew the people very well.

Each person had their need for staff support assessed individually by the local authority. The service provided staff support in line with these assessments. People received varying hours of support during the week dependent upon their assessed needs and this could vary from a few hours a week to 24 hours a day. Personalised support plans gave staff important information about people’s individual needs, preferences and the essential information staff must know to keep people safe. The regional manager had addressed the concerns that staff were not following the guidance in the support plans and were “doing things for people” rather than supporting them to do things for themselves. They confirmed that they and both registered managers were working in people’s homes more regularly. They said they were working alongside staff to review their practice and mentor staff in promoting people’s independence.

People were supported to identify goals they wished to achieve, such as being able to make a drink or snack, managing their own finances, or to be able to go out without staff. One member of staff told us they work “step by step” to help people achieve these goals. Technology was used to enhance people’s independence. For example, one person had an electric blind at their bedroom window to allow them to close this for privacy without staff assistance. Other people used finger print recognition locks to access their front door or bedroom within a shared house.

People’s support plans contained risks assessments which outlined measures in place to enable them to take part in activities both in and out of the home with minimum risk to themselves and others. Staff were given very clear information about their responsibilities to protect people from avoidable harm, such as when bathing. Some of the people receiving support could display behaviours that may put themselves or others at risk. HF Trust had a special support team of advisors who supported staff in assessing people’s needs and provided guidance to promote people’s positive behaviour. Guidance was also sought from the local authority’s learning disability intensive assessment and treatment team. Staff were provided with very clear information about what behaviours to be observant for should the person become anxious or distressed and how to respond to this.

People were able to take part in a range of activities according to their interests. A day services co-ordinator who facilitated planned events such as music, arts and craft and an employment team supported people to obtain voluntary or paid employment. People were supported to maintain contact and relationships with family. People were involved with daily living tasks such as food shopping, meal preparation, and tidying their bedrooms.

Many of the people supported by the service were unable to make decisions about complex issues such as medical treatment. Staff had a clear understanding of the Mental Capacity Act 2005 (the MCA) and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. However, where capacity assessments had been undertaken for people some of these assessments had not been fully completed.

People were supported to maintain good health and had access to healthcare services where required. Records showed people had seen their GP when they needed to and had been offered health screening. People had also been supported to attend dental, optician and chiropodist appointments.

People had access to the complaints procedure which was in an easier to read format with pictures and symbols to help people read it. For those people who were not able to communicate verbally, staff told us they would look for facial expressions and changes in behaviour to tell if a person was unhappy. A monthly ‘Voices to be Heard’ meeting for people to be involved and share their views. These meetings formed part of HF Trust’s ‘Voices to be Heard’ process to involve the people they support, to advise on how the service should be run and how people should supported.

During our inspection we visited two of these settings. We spoke with seven people who used the service and representatives for two other people who used the service. We also spoke with a senior manager, the registered manager, a health professional and six support workers.

People who use the service told us staff treated them with respect. We saw examples of support workers respecting people's privacy and dignity.

Care plans reflected the needs of the person they related to. These contained a comprehensive personal profile which included people's social histories and set out individual needs.

Support workers received regular supervision and appraisal. The service had ensured staff development needs had been identified and addressed.

There was an effective system in place to regularly assess and monitor the quality of the service provided.

We visited on this occasion because at our last inspection we found that there were areas where improvements were needed. The issues related specifically to a group of older people the service had recently started to provide care to. People were not always given information about who would be visiting them or for how long they would be staying. Also people's individual preferences and choices about their care were not always recorded in sufficient detail on care plans.

We found that some good progress had been made towards rectifying these matters, but that there was not yet full compliance in these areas.