Cera - Wiltshire

Cera – Wiltshire is a large domiciliary care agency that provides personal care to people in their own homes.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. Personal care 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’s medicines were not being safely managed. Audits had identified on-going errors, but more were identified at this inspection. Time specific medicines were not consistently given at the same time each day, and staff were giving one person their pain relief within the recommended time frame of four hours. This placed the person at risk of overdosing. Medicine administration records had not been accurately completed, and supporting documentation was not always available to ensure medicines were given as prescribed. Staff had received training in the safe administration of medicines, but not all had had their competency assessed.

Not all risks to people’s physical and mental health, had been identified and sufficiently addressed. This included one person’s risk of blood clots, and another person of very low mood, with the risk of suicide. Other risks associated with falling and the environment had been considered. Accidents and incidents had been appropriately documented and reported, with immediate actions taken where required.

Infection prevention and control measures were in place. This included staff training, large stocks of personal protective clothing (PPE) and a contingency plan in the event of high levels of staff contracting COVID-19. However, the staff testing programme was not mandatory, and staff were not expected to inform the registered manager if they had completed a test, or its outcome.

There were not always enough staff to ensure the reliability and efficiency of the service. This was particularly so at weekends or at times of staff sickness. Feedback from some people and staff, confirmed visits could often be late or not consistently at the same time each day. Staff recruitment was on-going and new staff were regularly starting employment at the service. Safe systems were in place to ensure those staff appointed, were safe to work with vulnerable people.

Systems were in place to help protect people from the risk of harm. Staff had received training in safeguarding and were aware of their responsibility to report any concerns. People felt safe with staff supporting them, and relatives had no concerns about safety.

People did not always receive a personalised service, which met their individual needs. Some timings of visits were inconsistent, and not always at a time to suit the person. Staff told us they had no, or sometimes very little travel time, which meant they were often late arriving to support a person. Some staff felt pressurised and found travelling between people’s visits stressful.

The content of people’s care plans was variable in detail and accuracy. One plan stated a person had a catheter but there was no information for staff about how to manage it. Another plan gave discrepancy, regarding the application of a person’s pain patch. Much of the information staff had recorded within the communication logs, was task orientated rather than person centred. A new electronic care planning system was being introduced to help these areas.

Management told us promoting social activity to avoid social isolation was an important part of the agency’s vision. However, not all staff took the opportunity to spend time with people, once all required tasks had been completed. Records showed some staff had left earlier, rather than use the time to reduce social isolation. The registered manager confirmed promoting social activity would be further addressed, once the restrictions of the pandemic eased.

People and their relatives were given a copy of the complaints procedure when they first started using the service. They knew how to raise a concern or a formal complaint if needed. Improvements had been made to the complaints process following a complaint which had been made before our inspection and not been handled well. This included a department within the organisation, reviewing any documentation before it was sent to the complainant.

Auditing systems were in place to assess and monitor the service. However, not all were effective as the shortfalls identified at this inspection had not been identified. Investigations into the root cause of medicine errors, or measures taken to minimise them, had not been adequate to ensure improvement.

Cera - Wiltshire is a large domiciliary care agency which provides care and support to people living in their own homes within Wiltshire. There were 313 people using the service at the time of the inspection. Not everyone who used the service received personal care. CQC only inspects where people receive personal care.

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

The feedback we received from people and relatives was mostly positive. Every person we spoke with told us they felt safe. This was in relation to staff conduct, the use of equipment and being able to summon help when needed.

People and relatives told us they mostly had no issues with their support regarding medicines. One person had specifically timed visits due to time critical medicines. Another person had some errors with their medicines administration and this was followed up with the registered manager. This part of the service had improved since our last inspection.

The provider had devised new care and support plans which were detailed, thorough and provided information and guidance to staff. Individual risk assessments were incorporated into the care plan specific to the person’s needs. There were actions to take and signs to monitor for staff to minimise the identified risk. This part of the service had improved since our last inspection.

The provider had developed more robust methods to audit the service. This meant any shortfalls were identified and actions taken to amend and improve the service given. This meant that people were receiving a service which was more closely monitored and well managed. This part of the service had improved since our last inspection.

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 requires improvement (published 21 June 2019).

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 21 June 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment and Good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of Safe, Responsive and Well-led.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cera – Wiltshire on our website at www.cqc.org.uk.

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.

People’s experience of using this service:

Following the last inspection, we recommended improvements to the timings of people’s support and better monitoring of the medicine administration records. We also recommended the provider ensured staff received appropriate training for them to be able to meet people's individual needs effectively. These recommendations had not been fully addressed.

People’s views about the timings of their support was variable. Some people said they did not always know when staff would arrive, and their timing was often inconsistent. Other people received continuity and were happy with the time staff arrived to support them. Communication logs, which showed the support staff gave, confirmed inconsistency in some people’s visits.

Medicines were not being safely managed. Records showed one person had been given too much of their medicine, because visits were not undertaken in line with the medicine’s prescription.

People were supported by staff who had received a range of training. However, bespoke training regarding people’s complex needs had not always been undertaken. The registered manager said this was in the process of being arranged.

Changes had been made to the allocation of care packages, as the agency was no longer the sole provider of the local authority’s Help to Live at Home contract. As part of an alliance, the agency was able to select packages in response to staffing capacity. This improved safety.

People were fully assessed before being offered a service. The assessments were placed on the person’s file but not all information was transferred to the individual’s support plan. This increased the risk of key information being missed. Some support plans did not detail health conditions or how these impacted on the person’s day to day life.

Whilst quality auditing systems were in place to check the safety of the service, these were not fully effective. This was because not all shortfalls were being identified.

Improvements had been made to the consistency of people’s support, as most people had regular staff supporting them. This gave increased satisfaction, as people were particularly complimentary about the staff who regularly supported them.

There were variable views about whether there were enough staff. The registered manager told us there were enough to support existing packages, but more staff were being recruited. Safe recruitment practice was being followed and new staff had a detailed induction, before they worked with people on their own.

People were encouraged to make decisions and give consent. People were involved in the development of their support plan and its review. They said any amendments to their support were made as required.

People told us they felt safe and staff were aware of their responsibilities to identify and report a suspicion or allegation of abuse. Any concerns had been appropriately reported and addressed.

People were encouraged to give their views about the service but not all knew how to make a formal complaint. People and their relatives told us any concerns raised, were appropriately resolved.

The ethos of the agency was to empower, enable and promote independence. People told us their rights to privacy, dignity and respect were promoted.

The inspection was announced. We gave the service 48 hours’ notice of the inspection visit because we needed to be sure that the registered manager would be available. This was the agency’s first inspection, since its registration in June 2017.

There was 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. The registered manager was available throughout the inspection.

This service was registered in June 2017. This was because the Amesbury and Melksham branches of Mears Help to Live at Home Wiltshire both merged to become one service, with a new registered address in Devizes. The registered manager transferred from the Amesbury and Melksham branches.

The agency was the main provider for the local authority’s Help to Live at Home contract. To ensure sufficient staffing, the agency subcontracted some care to other services. In addition, staff sickness meant staffing levels were not always sufficient. The registered manager told us they were in a process of recruiting more staff.

People were not always happy with the timing and consistency of their visits. There were comments that staff were sometimes late arriving and they did not always stay for the allocated amount of time. The electronic monitoring schedule confirmed some inconsistencies in people’s visits were occurring. We recommended that the provider monitors the timing of support to ensure it meets people’s needs and expectations. A “cell track” system was used to monitor people’s visits and minimise the risk of missed calls. This was not always effective as a number of missed visits had occurred through system errors and double up visits had not always occurred for one person.

People’s medicines were not always safely managed. Instructions for medicine administration were not clear and staff had not always signed the records to show the person had taken their medicines. However provider’s audits had identified such shortfalls and improvements were being made. We recommended further monitoring to ensure staff supported people with their medicines safely, in line with current guidance.

Staff received a range of training. However, this did not include training related to people’s individual needs and complex medical conditions in all cases. We recommended this training is delivered based on current best practice. People were positive about the competency of staff who supported them regularly but told us when new staff covered the calls they were not always familiar with their needs.

Risks associated with areas such as nutritional needs and mobility had been identified and action taken to promote safety.

People had a clear support plan, which they were involved in developing. The information was clear and showed the support people needed to meet the required outcomes. Staff documented a summary of their visit within a communication log. However, much of the information within the log, was task orientated and did not demonstrate areas such as how the person presented. People were asked for feedback about the service they received during reviews of their care. More formally, surveys were sent on a yearly basis to enable people, their relatives and staff to give their views about the service provided.

People were encouraged to make decisions and control the support they received. They were encouraged to be as independent as possible and their rights to privacy and dignity were promoted. Staff supported people with meal preparation where required.

Staff knew how to recognise and report when people experienced ill health. Additional visits were added to ensure people were properly supported if very unwell or there were risks to their safety. Records showed health and social care professionals were involved in the development and review of people’s support plans, as needed.

Structures and processes were in place to ensure day to day running and organisation of the agency. Systems such as recruitment and health and safety were well managed. There were a range of audits to assess the quality and safety of the service. There was an open approach to complaints and concerns received were fully investigated. Lessons learnt were taken on board and there was a strong emphasis on on-going improvement and development. Staff were aware of their responsibilities to identify and report any poor practice or allegation of abuse. Any safeguarding concerns had been appropriately managed, with disciplinary action taken as required.