Archived: Direct Health (Preston)

Direct Health (UK) is a limited company providing domiciliary care throughout the country. Direct Health (Preston) is a local branch situated on the outskirts of Preston City Centre. The agency provides personal care services to support people to live independently in the community.

At the time of our inspection there were 100 people using the service and 49 care workers appointed.

The service did not have a registered manager in post. The last manager left the service following enforcement action having been concluded. An interim manager was providing cover and in the process of applying to be registered to become the registered manager. 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 last inspection on 02 June 2016 we found the provider was in breach of legal requirements of the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014, in respect of staffing, safe care and treatment, dignity and respect, safeguarding service users from abuse and improper treatment and good governance. They sent us an action plan telling us what they were going to do to meet the regulations.

At this inspection, we found significant improvements had been made in respect of all areas except medicine management. We found some improvements had been made in respect of managing people’s medicines safely however, we found some ongoing concerns which demonstrated that the provider needed to make further improvements in this area. You can see what action we told the registered provider to take at the back of the full version of the report.

We saw copies of satisfaction surveys that had been completed by the people. These demonstrated people were satisfied with their care and the staff who supported them.

We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found there were policies and procedures on safeguarding people. Staff had received up to date training in safeguarding adults and they showed awareness of signs of abuse and what actions to take if they witnessed someone being ill-treated.

Safeguarding incidents had been investigated and documented, showing the support people were getting after incidents. Staff had sought advice from other health and social care professionals where necessary. There were risk assessments which had been undertaken. Plans to minimise or remove risks had been drawn and reviewed in line with the organisation’s policy. These were robust and covered specific risks around people’s care in a person centred manner.

We found people’s medicines had not been managed safely. This was because the service had not effectively managed the needs of people who required topical creams. We found records relating to medicine administration had not been adequately completed to show whether people had received their medicines. There were a considerable amount of medicine administration errors related to topical creams. However, staff had received regular training and competence checks in safe management of medicines. The medicines administration policy was not robust to provide clear guidance for the administration of topical creams however it was under review.

Lone working and environmental risk assessments were in place to ensure the safety of care staff and people they support. During the inspection we observed staff were visiting to people at the planned and agreed times and there was a significant improvement on ensuring care staff stayed the duration of the visits. Regular monitoring checks had been undertaken and action taken for those staff who had been found to be cutting visits short.

We looked at recruitment processes and found the service had recruitment policies and procedures in place to help ensure safety in the recruitment of staff. These had been followed to ensure staff were recruited safely for the protection and wellbeing of people who used the service.

Records we saw and conversations with staff showed the service had adequate care staff to ensure that people's needs were sufficiently met. The majority of the people and their relatives told us they were happy with the staff and their consistence.

We found care planning was done in line with Mental Capacity Act, 2005. Staff showed awareness of the Mental Capacity Act, 2005 and how to support people who lacked capacity to make particular decisions. They had received mental capacity training.

People using the service had access to healthcare professionals as required to meet their needs. Staff had received mandatory training. Care Certificate induction training was available. Staff competences were checked regularly in various areas of practice including moving and handling, medicine administration and food hygiene. Staff had received supervision through spot checks and supervision meetings at the office. They had also been provided with annual appraisals.

We found that people’s care needs were discussed with care commissioners before they started using the service to ensure the service was able to meet their assessed needs.

Care plans showed how people and their relatives were involved in discussion around their care. People were encouraged to share their opinions on the quality of care and service being provided. We saw surveys had been carried out to seek people’s views and opinions about the care they received.

People’s nutritional needs were met. Where people's health and well-being were at risk, relevant health care advice had been sought so that people received the treatment and support they needed.

Management systems at the service were robust. Senior management had been involved in the day to day management of the service. A new manager had been recruited and oversight had been provided on delegated duties.

Quality assurance systems were in place and various areas of people’s care been audited regularly to identify areas that needed improvement. We found audits had been undertaken of care records, and medicine administration records, however; some audits for previous months did not have action plans to show how shortfalls had been rectified. However we were shown new action plans that had been implemented and were to be used in the future. We were assured that these would ensure that any issues identified in audits will be acted on.

There was a business contingency plan to demonstrate how the provider had planned for unplanned eventualities which may have an impact on the delivery of regulated activities.

Surveys we saw showed people felt they received a good service and spoke highly of their staff. Relatives told us the staff were kind, caring and respectful. Professionals we spoke to confirmed this.

We found the service had a policy on how people could raise complaints about their care and treatment.

We carried out an announced comprehensive inspection of this service on 25th February 2015 and 6th March 2015 at which breaches of legal requirements were found. This was because proper steps had not always been taken to ensure people were protected against the risks of receiving inappropriate or unsafe care or treatment. Care and support was not person centred; people were not protected against the risks associated with the unsafe use and management of medicines. People were not protected against the risks of unsafe or inappropriate care because accurate records were not always maintained and records could not be located promptly when required.

Systems for assessing and monitoring the quality of service were not robust; risks had not been well managed, the service was unreliable and some staff providing care and support did not have the competence, skills and experience to do so safely. Suitable arrangements were not in place in order to ensure that persons employed were able to deliver care to people safely and to an appropriate standard. This was because appropriate induction, training, supervision and appraisal were not arranged for all staff members.

As a result of our findings we requested the provider to give us an action plan on how they were going to meet the requirements of regulations 9, 13, 20 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, regulations in force at the time.

During this inspection we reviewed actions taken by the provider to gain compliance against the four breaches from the previous inspection in January 2015. We also looked to see if improvements had been made in respect of the additional shortfalls in people's care we had identified. We found some improvements had been made in respect of person centred care planning, and staff training, induction and maintenance of care records. However little in the way of improvements was found with respect to safe management of medication and systems for assessing the quality of service. We found further deterioration in the quality of care as a result of lack of adequate staff supervision and insufficient leadership and oversight.

Direct Health (UK) is a limited company providing domiciliary care throughout the country. Direct Health (Preston) is a local branch situated on the outskirts of Preston City Centre. The agency provides personal care services to support people to live independently in the community.

At the time of our inspection there were 153 people using the service and 70 care workers appointed.

The registered manager of the service was present throughout 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.

People were not protected against avoidable harm and quality assurance systems at the service failed to resolve associated risk, therefore placing people at significant risk of harm. We found people's safety had been compromised in a number of areas. This included how people were assisted to manage their medication, and the how people’s risks were identified and managed. Risk assessments did not accurately reflect how people were cared for.

We looked at care assessments undertaken for six people. Some risk assessments had been carried out. However, risk assessments did not state how people were being supported to reduce risks.

The service was unreliable because carers did not visit as planned. They were either late, too early or did not stay the duration of the call. This had exposed people to risk of improper treatment and care.

Good governance had not been maintained. Although there were systems and processes in place they had not been carried out effectively to ensure required improvements were made to the service. Audits had been completed however actions had not been carried out in a timely manner. The service had not adequately addressed the breaches that we found in January 2015. There was lack of robust oversight and leadership. Staff were not adequately supervised to ensure their performance was monitored and poor practice was addressed.

We looked at recruitment processes and found the service had recruitment policies and procedures in place to help ensure safety in the recruitment of staff. People’s views on the service’s reliability were positive however we found the service was unreliable.

The service followed safeguarding reporting systems as outlined in its policies and procedures. Allegations of unsafe care had been identified and actions had been taken to investigate and safeguard people.

We found the service had promoted staff development. New staff had been provided with induction and training before their started their role. A range of on-going training programs had been undertaken. Staff told us they could access training if they needed it and additional training had been provided to staff who needed to develop their skill and competence.

We looked at how the service gained people’s consent to care and treatment in line with the Mental Capacity Act [MCA]. People's care records had evidence of mental capacity assessments and consent.

Feedback about care staff and the care that people received was mixed. Some people felt care staff were excellent however some people raised concerns about some care staff’s professional behaviour and poor time keeping. We found the way people's needs were being met was not consistently person centred. People’s care files contained details about people’s likes and dislikes. People told us care staff were introduced to them before providing care. There were assessment processes in place, which helped to ensure staff had a good understanding of people's needs before they started to support them.

Staff feedback about management was mixed. Some staff felt supported however other care staff felt management were not effective in dealing with the challenges that the service faced. Some staff did not feel management dealt robustly with care staff whose behaviour had been found to be below professional standards. We looked at staff meeting minutes; they showed staff were involved in discussions about improving the service. Some staff however expressed they did not always feel their contributions made a difference to the service; they felt management did not act on suggestions. Management encouraged the staff team to provide good standards of care and support.

The service had a complaints procedure which was made available to people they supported. People we spoke with told us they knew how to make a complaint if they had any concerns. Evidence we saw showed people’s concerns about staff had not been dealt with transparently.

Following our inspection the provider decided to take action to put themselves in voluntary embargo on all new work. This meant that the provider stopped accepting new service users until they had met the regulations.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These included Regulation 10 - Dignity and respect, Regulation 12 – Safe care and treatment, Regulation 13- safeguarding service users from abuse and improper treatment, Regulation 17 –Governance and Regulation 18- Staffing. You can see what action we have taken at the end of this report.

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.

Care assessments and care plans were in place and these were followed in practice. We found that people had the same team of carers and they arrived on time for their visits. One person said, 'I always have the same carer in the morning. She knows exactly what I want and that's great because I don't have to worry about it.

We found that safe and effective recruitment processes were in place and that the service had a staff team that was appropriately qualified and experienced to provide a safe and effective service. A staff member said, 'The training is brilliant and it's constantly updated. We get to give our views about the service and they (the managers) listen to us'.

People who used the service and staff were able to give their views about the service. Systems were in place to assess and monitor the quality of the service that people received. An effective complaints system was in place.