Town & Country Homecare Limited

Town and Country Homecare is a domiciliary care agency providing personal care to people in their own homes. The service was supporting 90 people at the time of inspection, including older people, those living with Dementia and people with a physical disability.

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.

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

People and their relatives told us they felt safe using the service and care staff knew how to report concerns of abuse.

Since our last inspection improvements had been made to safely manage and mitigate risks to people. New risk assessments were implemented where necessary and were reviewed regularly. People were receiving their medicines safely and improvements had been made to the recording and oversight of medicines management. Care staff were recruited safely and people were positive about the care they received from staff that knew them well.

Improvements had been made to people’s care plans. They had been reviewed and updated to ensure relevant and up to date information was available for staff to follow. Where people experienced heightened emotions, care plans were implemented to help staff to support them in the best way. Staff training delivery had been changed to a new online system and staff were positive about this change. Lots of training had been made available to help meet people’s needs more effectively. People were supported to eat and drink to maintain a healthy diet.

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 and their relatives were happy with the care and the support they received from the service. They told us staff were kind and caring. People were supported to remain independent and had their dignity respected at all times.

People were involved with their care plans and had reviews carried out with the management team since our last inspection. People felt more involved and care plans were updated and implemented where necessary to provide personalised care. Care plans to help people to talk about end of life care had been implemented and care staff were now receiving training to help support people receiving palliative care.

A new quality assurance system was put in place to ensure effective oversight of the service. Audits were now being carried out on a variety of areas such as medicines and care people are receiving through care notes and charts. Accidents and incidents were also being analysed and reviewed for patterns and trends. Feedback had been sought through questionnaires and actions taken. Meetings were now being carried out with the staff to improve communication. People, relatives and staff were all positive about the management team. Care staff felt supported by their manager and felt confident to raise concerns.

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 24 February 2023) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Town and Country Homecare is a domiciliary care agency providing personal care to people in their own homes. The service was supporting 93 people at the time of inspection, including older people, those living with Dementia and people with a physical disability. 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.

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

There were a lack of quality assurance systems in place. There were no audits being undertaken so risks to people and concerns had not been identified. People and their relatives were not asked for their opinion, so the provider could not continuously learn and improve the service. The registered manager was not fully aware of the duty of candour.

People’s individual risks around health and other conditions were not well managed. Risk assessments were not always in place to assess, manage and mitigate risks to the health, safety and welfare of people. Care plans did not always include relevant information for staff to follow. Medicines were not managed safely.

Lessons were not learnt when things had gone wrong; there was no process for reviewing and acting on learning following accidents and incidents. Staff were recruited safely. Staff understood their safeguarding responsibilities and people told us they felt safe.

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.

We could not be sure people were always supported to be involved and make their own decisions about care as they were not asked for their opinion. Care was not always personalised, and care plans lacked detail. People who were receiving palliative care did not have end of life care plans in place.

There were enough staff to support people in a timely manner. People felt well-treated and staff treated people with dignity and respect.

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 24 February 2018).

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. You can see what action we have asked the provider to take at the end of this full report.

Why we inspected

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

Enforcement and Recommendations

We have identified breaches in relation to person-centred care, consent, safe care and treatment, and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report. 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.

Town and Country homecare is a domiciliary care agency. It provides personal care to people living in their own houses and flats. It provides a service to older adults and younger disabled adults. Not everyone using Town and Country homecare receives regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided.

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

Following the last inspection, on 21 September 2016, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good. At our previous inspection we found breaches of regulation relating to the management of risks, the management of medicines and personalised care. We carried out this inspection to check on the improvements the registered provider told us they had made.

The registered provider had not consistently followed the principles of the Mental Capacity Act 2015 (MCA). Some MCA assessments had been completed that were not in relation to a specific decision that the person needed to make. The registered provider made the necessary improvements and provided us with evidence of this immediately following the inspection. We made a recommendation that the registered manager continues to review the implementation of the Mental Capacity Act 2015 principles in the service to ensure they are followed consistently.

The service was not yet using the Care Certificate for staff that were new into care roles. We made a recommendation that the registered provider seek further advice on using the Care certificate or a similar qualification to ensure staff receive an appropriate induction.

People were safeguarded from harm and abuse. The registered provider worked proactively with the local safeguarding team to respond to allegations of abuse. They ensured that lessons were learned when things went wrong. Staff knew what action they needed to take to reduce risks and to provide safe care and support. Improvements had been made to risk assessments to ensure staff were provided with detailed guidance about the action they were required to take to keep people safe. The premises were well maintained and equipment had been checked regularly to ensure it was suitable and safe. The registered provider ensured that the risk of infection in the service was assessed and managed.

There were sufficient numbers of skilled and competent staff working in the service to meet people’s needs. The registered provider ensured that staff were safe and suitable to work with people. Staff received appropriate training and support and were enabled to develop their knowledge and skills through qualifications. Staff had positive relationships with the people they cared for. They understood the individual ways that each person communicated and provided appropriate support to enable their views to be heard.

People received safe support to manage their medicines. People were supported to stay healthy and staff enabled them to access healthcare professionals as needed. People had a balanced diet and enough to eat and drink. The registered provider ensured that care was planned in line with best practice guidance. They worked effectively with partner agencies to deliver safe and effective care.

People and their relatives told us that the staff provided a responsive and reliable service. Improvements had been made to ensure that people are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. People had choice and control over their lives. Their care was flexible and person centred. People were involved in developing their care plans and making decisions about their care. People were treated with dignity and respect. Their right to privacy was upheld. People were supported to be independent, and to be as involved as much as possible in their own care. The policies and procedures for the service ensured that people’s rights were protected. Staff provided care that respected the diverse needs of the people they supported.

People were asked their views of the service and their feedback led to improvements. They knew how to make a complaint if they needed to and were confident they would be listened to.

People and their relatives felt the service was well led. They were happy with the care they received and told us the registered manager was approachable if they needed to discuss any changes to their care. The service had a set of vision and values that focused on providing personalised care, which staff understood. The registered manager monitored the quality of the service to ensure care was delivered in line with these values.

This is the first consecutive time the service has been rated Requires Improvement.

Town & Country Homecare Limited provides care and support to people in their own homes. The service is provided to mainly older people and some younger adults. At the time of the inspection there were approximately 107 people receiving support with their personal care. The service undertakes visits to provide care and support to people in Tenterden, Cranbrook, Rye and surrounding villages. It also provides staff to cover wake night and sleep in duties within people’s homes and a sitting service.

The service is run by a registered manager who was registered with the Commission in September 2015. 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 told us they received their medicines when they should and felt their medicines were handled safely. However there were shortfalls in some medicine records and a lack of guidance about some areas of medicine management.

Risks associated with people’s care had been identified, but there was not always sufficient guidance in place for staff, to ensure people remained safe.

People were involved in the initial assessment and the planning of their care and support and some had chosen to involve their relatives as well. However care plans varied in the level of detail and some required further information to ensure people received care and support consistently and according to their wishes. People told us their independence was encouraged wherever possible, but this was not always supported by the care plan.

There were audits and systems in place to monitor that the service ran efficiently. These had been effective in identifying most of the shortfalls highlighted during the inspection, but not all.

People felt safe using the service and when staff were in their homes. The service had safeguarding procedures in place. Staff demonstrated an understanding of what constituted abuse and how to report any concerns in order to keep people safe.

People had their needs met by sufficient numbers of staff. The majority of people’s visits were allocated permanently to staff schedules and these were only changed when staff were on leave. People received a service from a team of regular staff. New staff underwent an induction programme, which included relevant training and shadowing experienced staff, until they were competent to work on their own. Staff received training appropriate to their role and more than half of the staff team had gained qualifications in health and social care.

People told us their consent was gained at each visit. People were supported to make their own decisions and choices. No one was subject to an order of the Court of Protection although people had made Lasting Power of Attorney arrangements and some people had a Do Not Attempt Resuscitation (DNAR) in place. Some people chose to be supported by family members when making decisions. The Mental Capacity Act provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals, where relevant. The registered manager understood this process and had recently made improvements to ensure all legal arrangements and best interest decision making would be recorded.

People were supported to maintain good health and they told us how observant staff were in spotting any concerns with their health and taking appropriate action.

People felt staff were very caring. People said they were relaxed in staffs company and staff listened and acted on what they said. People were treated with dignity and respect and their privacy was respected. Staff were kind and caring in their approach and knew people and their support needs well.

People told us they received person centred care that was individual to them. They felt staff understood their specific needs relating to their age and physical disabilities. Staff had built up relationships with people and were familiar with their personal histories and preferences.

People told us that communication with the office was good and if there were any queries they telephoned and action was taken. People felt confident in complaining, but did not have any concerns. People had opportunities to provide feedback about the service provided. People felt the service was well-led and well organised. There was an open and positive atmosphere in the office and staff were committed to improving the service people received.

The provider’s aim for the service was included on their website and we found these principles were followed through into practice.

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

During this inspection we spoke with eight people who used the service, two relatives and two members of the management team.

People told us they continued to be satisfied with the care and support they received. People's comments included, 'They are marvellous, I'm very happy with it' and 'It's very good'. We found that care plans were being updated to include information about people's wishes and preferences and the steps staff should take to ensure people remained safe.

People felt they were able to make their own decisions and choices regarding their day to day care and support. People confirmed that they had given their consent and been involved in discussions about their care, sometimes with a family member, when the service had first started.

Most people said they were satisfied with the care and support they received. One person said, 'I think Town and Country are excellent'. Another person said, 'They are efficient, very good and we laugh a lot together'. One person we spoke with was not happy with the service they received and this was fed back to the manager. We found that care plans contained information about the tasks staff needed to undertake, but lacked detail about people's wishes, preferences and abilities to ensure care and support was delivered to promote their independence. People knew about their care plan or confirmed that staff had talked about the care and support they required. Care was delivered generally by a regular team of care workers to ensure people had continuity.

People felt they received safe and coordinated care and support where more than one provider was involved.

People were complimentary about the staff and felt the service recruited the right calibre staff to meet their needs. One person said, 'The girls we have are pleasant, helpful and understanding'. Another person said, 'They are varied, but good'.

People said they had been asked for their views and feedback on the service provided. One person said, 'They visit every six months and go through it all, the care plan and whether the staff wear their gloves etc.' People told us they felt confident that any concerns would be addressed. There were systems in place to monitor the quality of the service.

People and carers told us that they felt treated with respect and had been included in their care planning. One told us that "they do put their customers as the priority".

We saw that the provider had suitable safeguarding procedures in place and that these had been used when needed. We saw that staff had been trained in safeguarding and this was confirmed to us by staff we spoke to.

We saw that staff had received training appropriate to their roles, including specialist training such as dementia, and that this was updated as necessary.

We saw the provider had quality assurance systems in place to assess and monitor the quality of service people received.