Altonian Care Ltd

At our last inspection we rated the service good overall, but requires improvement in the key area of safe, where we found one breach of the regulations. At this inspection we found the evidence continued to support the overall rating of good, the breach had been met and now the key area of safe is also judged to be good. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

The provider operated safe recruitment processes. People received continuity of care from regular staff. Systems were in place to monitor the capacity of the service to provide people’s care and relevant actions had been taken to ensure people received their care safely, when there was pressure on staffing capacity.

Staff had undertaken relevant training and processes were in place to safeguard people from the risk of abuse. Risks to people had been assessed and managed to ensure their safety. Processes were in place to ensure people received their medicines safely from trained staff. People and staff were protected from the risk of acquiring an infection. Staff understood the requirement to report any concerns to the provider. Where required, investigations were completed and improvements to the service made for people.

People’s needs had been assessed and their care was delivered in accordance with current legislation and guidelines. People were supported by staff to eat and drink sufficient for their needs and to ensure their health needs were met. Staff could provide end of life care to people as required. Staff were supported to provide effective care to people through the provider’s induction, training and supervision processes.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received responsive and adaptable care that was tailored around them and their interests.

People were treated by staff in a caring manner and provided with the emotional support they required. People were encouraged to express their views and to be actively involved in decisions about how they wanted their care provided. People’s privacy, dignity and independence were respected and promoted by staff.

There was an open culture and clear values which underpinned the delivery of peoples’ care. There was a registered manager to run the service who understood their legal responsibilities. Processes were in place to seek and act upon people’s and staff’s feedback and to monitor the quality of the service provided. Processes were in place to enable people to make a complaint and any issues raised were investigated and addressed for people. The service worked in partnership with other organisations to ensure people received high quality care.

Further information is in the detailed findings below.

The service had a 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 2008 and associated Regulations about how the service is run.

We previously carried out an announced comprehensive inspection of this service on 29 February and 1 March 2016. Breaches of legal requirements were found in relation to safe care and treatment and clinical governance. The provider was served with two warning notices that they were required to meet by 30 June 2016. Following the inspection the provider sent us an action plan detailing how they would meet the regulatory requirements by the required date. At this inspection we found the requirements of these regulations had been met.

At this inspection we found action had been taken to ensure people received their medicines safely. Staff were required to undertake medicines training, followed by an assessment of their competency to administer people’s medicines. Improvements had been made in relation to the processes for recording people’s medicines. The registered manager planned to introduce topical cream charts to provide staff with visual guidance for their administration, in addition to the written guidance available.

Staff received an induction to their role based on industry requirements. The registered manager had determined the staff mandatory training requirements and staff were required to keep their knowledge up to date. Staff were supported in their professional development and received regular supervision of their work which included observations of their practice to check their competence to deliver people’s care.

Since the last inspection the registered manager had reviewed the robustness of the systems they had to enable them to deliver people’s care and to monitor the quality of the service provided. Processes were now in place to enable them to audit people’s medicine records effectively. There were also systems to enable the registered manager to identify and address staff training and supervision requirements. People’s views on the service had been sought and action had been taken where required in response to the feedback received, to improve the service for people.

The registered manager had completed recruitment checks in relation to staff. However, they had not always ensured that applicants had provided the date when they completed their full-time education to enable them to establish if they had a full employment history, nor had they always sought an explanation for any gaps in the applicant’s employment history. There was the potential that people might have been placed at risk from the recruitment of staff as the provider had not always fully assured themselves of their suitability for their role.

People and their relatives told us they received consistency in their care staff. People received their care on the days they needed it and at the times they required. Staff were now expected to use the electronic system to ‘log-in’ and out of people’s calls to ensure a record of the call time and duration was maintained.

Staff had undertaken safeguarding training and understood their role in relation to safeguarding people from the risk of abuse. Safeguarding alerts had been made to the local authority by the registered manager as required to safeguard people from the risk of abuse.

People had risk assessments in place which identified risks to them and the measures required to ensure they were managed safely for them.

People told us staff sought their consent before they provided their care. Staff had undertaken training in relation to the Mental Capacity Act (MCA) 2005 and understood how it applied to their day to day work with people. The registered manager told us that currently all of the people they cared for had the capacity to consent to the provision of personal care from the service. They had a copy of a MCA assessment tool available to enable them to do a MCA assessment if they identified that a person might lack the capacity to make a specific decision.

Staff had guidance about what assistance people needed to eat and drink. People were adequately supported by staff to eat and drink sufficient amounts for their needs.

Relatives told us staff supported people to maintain good heath which records confirmed. Staff reported any concerns with people’s health to the office, to ensure they could be addressed for people.

People provided very positive feedback about the quality of the relationships they experienced with staff. People’s care was provided by staff who understood the need to communicate with, and to build a relationship with, the people to whom they were providing care.

People told us staff supported them to express their views and to make decisions about their care. Written guidance was available for staff about people’s care preferences and they were able to tell us how they supported people to make decisions about their care.

People’s privacy and dignity were respected and promoted by staff during the provision of their personal care.

People’s needs had been assessed prior to them receiving a service. People told us that the service was responsive to changes in their care needs. People’s care plans contained sufficient background detail about people for staff; however, work was being completed to identify if peoples’ care plans could be further enriched with additional information about people. It will take further time to complete this.

There was written guidance for staff in the event that people experienced a medical emergency related to their diabetes or epilepsy. Work was underway to provide staff with written guidance in relation to other types of health conditions.

People and their relatives told us they had not had cause to make any written complaints but they felt confident any concerns would be listened to and responded to. Where people had raised issues verbally, action had been taken for them to address the issue.

People, their relatives and staff told us there was regular, transparent communication with the service. Staff said they felt their concerns were listened to. Staff were guided in the delivery of people’s care by a clear set of values.

People, their relatives and staff told us the service was well led. They found the registered manager to be accessible and supportive. The registered manager had taken measures since the last inspection to ensure they had sufficient time to carry out their management responsibilities.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

The service has a registered manager who is also the provider; they work within the service managing it on a daily basis. 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.

Medicine audits were not effective and MARs had either not been audited or contained gaps that had not been identified or addressed, this had placed people at risk of unsafe medicines administration.

There was a lack of robust systems to assess the quality of the service people received and to identify any potential risks to people. Information generated from incidents, care calls and staff training and staff supervisions for example, had not been used to monitor the quality of the service people received or to identify any trends in relation to people’s care to ensure their safety.

Accurate and complete records were not always maintained. People’s views on the service had been sought however there was a lack of evidence to demonstrate feedback had been used to drive service improvement.

The provider had not ensured that when staff joined the service from other providers that they had obtained written evidence of their medicines training prior to them being rostered to administer people’s medicines. There was a lack of evidence to demonstrate staff’s competency had been assessed following medicines training. People’s MARs were hand written and not checked for errors. Although there was no evidence that people had come to harm, people had been placed at potential risk of harm from unsafe medicines administration.

Records showed not all staff had completed training in areas such as safeguarding, Mental Capacity Act (MCA), and moving and handling. Staff had been rostered to support people with moving and handling without written evidence of their qualifications and competence to do so. Although there was no evidence that people had come to harm, people had been placed at potential risk of harm from unsafe or ineffective care.

People provided positive feedback about staffing. They told us they received consistency in their care and that staff stayed the required length of time. The provider did not have a formalised system to plan for their staffing needs, but they understood staffs availability and the capacity of the service to take on new packages of care. The provider had not ensured they had monitored the duration of people’s calls, to ensure they received calls of the required length. The provider had completed relevant pre-employment checks upon staff to ensure their suitability to work with people.

Staff told us they felt supported by the provider in their role. Staff records demonstrated staff had received some one to one supervisions and spot checks of their work. However, as the provider did not keep a central record of these, there was a lack of written evidence to demonstrate that staff were sufficiently supported, to ensure they could support people effectively.

People told us that they felt safe from abuse or harm. Staff told us that they knew what to do if they suspected that someone was being abused or was at risk of harm. The provider did not have a robust system in place for recording their management of safeguarding concerns, to demonstrate the actions they took and to be able to demonstrate people were adequately safeguarded.

People had risk assessments in place which identified risks to them personally and from their environment and the measures required to ensure they were managed safely for them.

People told us staff sought their consent before they provided their care. The provider was able to give an example of a MCA assessment they had completed for a person, who lacked the capacity to make a particular decision themselves. However there was a lack of written records to demonstrate how this decision had been reached. We have made a recommendation that the provider seeks further guidance on the MCA in relation to the recording of assessments.

People’s care plans documented their food preferences. Risks to people in relation to eating and drinking had been assessed and measures taken to mitigate them, for example, by recording their food and fluid intake. Improvements could be made to these records to ensure they were fully effective. Staff had guidance about what support people needed to eat and drink. People were adequately supported by staff to eat and drink sufficient for their needs.

People’s records provided details of relevant health care professionals. Records demonstrated staff had contacted people’s GP or district nurses where required. They had also supported people to attend healthcare appointments. People were supported to maintain good health.

People told us that they were treated with kindness and compassion by their care workers.

People’s daily routines were documented in their care plans to ensure staff were aware of people’s preferences. Staff involved people in making decisions about their care. People’s communication needs were noted in their care plans. However there was not always clear written guidance for staff about how they should support people in relation to this need. People experienced positive relationships with staff.

People’s privacy and dignity were respected and promoted. Although on rare occasions we observed staff could have improved their practice in relation to how they upheld people’s privacy and dignity. However, this was not reflective of the service as a whole. People’s privacy and dignity were maintained.

People told us that the service was responsive to changes in their needs. People’s needs had been assessed prior to them receiving a service. The provider had been responsive to changes in people’s care needs.

The provider had used different documentation to document people’s care needs and this had led to variability in the content of people’s care records. Some care records contained a greater amount of information and guidance for staff than others. Although there was written guidance for staff in the event people’s behaviours challenged them there was no guidance for them about what to do if a person with diabetes required support during a call. Although people told us staff knew the actions to take, this was not actually documented to ensure staff unfamiliar with the care of such persons had access to relevant guidance.

The provider told us people’s care was reviewed with them on a three monthly basis. However, there was a lack of written evidence to demonstrate people’s reviews of their care by the provider had always taken place as frequently as required.

People told us they had not needed to complain but felt they could do so if needed. The provider ensured people had access to information about how to complain.

People felt that management had insufficient time to manage the service and were not sufficiently organised. Staff told us they felt well supported by management. The provider was heavily involved in the delivery of the service as were other office staff. This left insufficient time for them to focus on overseeing and leading the service. People’s care had been impacted upon negatively by the lack of leadership as demonstrated by the issues identified during the inspection.

People told us they had observed a positive culture overall amongst the staff. The provider had a set of values for staff to apply in their work with people, which staff understood. The provider had not consistently upheld their own values in relation to ensuring people’s safety or the quality of service.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.