CQC report : Our findings

All of the people we spoke with had positive comments about the service. People thought the service worked consistently well and they felt safe with their care workers. Comments included “I feel very safe when they are around they carried out a risk assessment on me and my house, to make sure things were ok. They lock my key up in a safe outside so they can let themselves in. They are wonderful” and “The same girls (staff) come here all the time. They know my house and they know my needs. They look after me well and kept me safe”. Relatives of the people who used the service said they trusted the staff very much. Comments included “The staff are well trained and have good backup support if needed”, “Staff are protective of my relative they always ring me up if there are any problems” “This service enables my (relative) to stay in their own home” and “I completely trust the management and staff they know exactly what they are doing. They carry out safe care which puts my mind at ease”. We saw that a weekly roster was provided to the people who used the service advising them of the times of their visits and showing photographs of the staff who would be calling. The people who used the service told us that they felt this was an innovative way of identifying the staff and ensuing people knew who was calling. One person told us that this was especially useful as their relative was living with dementia and needed to know who was calling and why.

They told us that showing them the staff photograph reassured them. They also said that this system also made them feel safe in the knowledge they knew beforehand which staff member was calling and what they looked like. We saw examples in care plans where risks had been identified and plans put in place to minimise these risks. For example in one care plan it stated that the person may forget to take their medicine and staff must always ask and check if this had been done. In another it was clear that two care staff would be required to ensure the person was safely assisted to move. In all the care plans we looked at we found that risks associated with the care to be delivered were described and detailed how to minimise these potential risks. The service had a policy and procedure in place for the protection of people from abuse, which was included in the staff handbook. We saw that information ‘if you have concerns about someone who may be vulnerable and at risk of harm, abuse or neglect’ was covered in the documentation provided to people who used the service. This information included a guide as to safeguarding people and who to contact if people had any concerns. We asked staff about how to recognise any potential signs of abuse. They had a good understanding of safeguarding vulnerable people and were able to describe the action they would take if a concern arose.

We noted from the training records that not all staff had undertaken training in safeguarding. The registered manager told us that the staff who had not yet undertaken the training were booked to do so before the end of December 2015. The training matrix identified that this training had been booked. The service operated detailed recruitment procedures and we looked at three of these processes for recently recruited staff. We found that Disclosure and Barring Service (DBS) checks had been carried out, which included police criminal record checks. References were obtained prior to an offer of employment being made and checks were also undertaken to verify the validity of the references provided. The service had arrangements in place to deal with emergencies, whether they were due to an individual’s needs, staffing shortages or other potential emergencies. We were told by staff that they operate a 24 hour on call service and have a special measures policy in place in the event of bad weather conditions. One person who used the service told us that they had needed emergency assistance and staff ‘were there like a shot’. The service was not responsible for obtaining medicines on behalf of anyone who used the service. The need for care staff to prompt or otherwise assist people to take their medicines was clearly set out within the care plan, which had been agreed with the person or their representative. However there was some inconsistency in the recording methods. The majority of medicine recording was written in the care records, however other records were written on medicine administration records (MAR). The recording of medicines prompted from a NOMAD pack was not clear as to what medicines had been taken or refused. This was because the NOMAD was prepacked by a local pharmacist and could hold as many as eight tablets to be given at one time. Staff were unaware of what the medicines were and if a person refused to take one or more of the tablets staff did not know what these tablets were refused but could not identify specific tablets. Discussion with staff highlighted the issue and they contacted the pharmacies involved to check if they could suggest a better system. Unfortunately this could not be done and as a consequence the service had commenced a system in which they had drawn up their own system were medicines records would be completed only on a MAR sheet. They said that they would also ask local pharmacists if they could provide a picture and description of each tablet to enable staff to identify any medicines which people may refuse.

As far as we could see the medicines records were appropriately completed at the time of our visit. We were provided with a copy of this newly introduced MAR sheet before the end of our inspection. We saw that staff were provided with a bag that contained arm and shoe protectors, gloves, aprons, masks and hand gel to be used as appropriate. Staff told us that they had received training in infection control and used the equipment provided to minimise the risk of infection.

People we spoke with felt that staff were suitably skilled to provide them with care. Comments included “The staff are excellent, they are angels and know exactly what I want and when I want it”, “The staff are always on time and provide me with proper care because they know what they are doing” and “They understand my needs, speak to me in my language and I love them all”. A relative told us “I am so pleased with them (Spiritual Inspiration) the staff are wonderful, they communicate with me very effectively, they are so good I feel I can now take a step back as I trust them to provide quality care for my (relative). We spoke with the registered manager and senior co-ordinator who explained the system used for both mandatory and optional training courses. We found the mandatory training covered core skills and knowledge for staff and induction was in line with the Skills for Care Common Induction standards. Staff training records showed that staff had received core training and updated training at periodic intervals. This meant that staff were supported to develop the skills and knowledge required to provide the most appropriate care for people. We looked at the training matrix and saw that in most cases, mandatory training had been undertaken. The staff training records also listed the dates by which refresher training had to be undertaken and this supported the service philosophy that people were only supported by staff with the necessary skills. Staff told us that they felt that training opportunities provided them with the knowledge they needed to provide care and support and the feedback given about the quality of training was positive from staff. We saw that not all staff had yet fully completed their training but noted that all mandatory training was booked to take place before the end of December 2015. We talked with the registered manager and senior co-ordinator and care staff about how they were supported.

We were told that there was an effective communication system in place and managers and staff either spoke in the telephone or used texting facility to make daily contact. Staff told us they were offered both formal and informal supervision. Informal supervision was an on-going process where the registered manager picked up on issues of particularly good or poor practice. Supervision records showed that formal supervision sessions were held every three to four months were pre-arranged and time managed. Records showed that staff had the opportunity to reflect on their achievements, what had gone well and future development needs. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to refuse care and treatment when this is in their best interests and legally authorised under MCA. The authorisation procedures for this in care homes are called Deprivation of Liberty Safeguards (DoLS). Although DoLS procedures do not apply to domiciliary care the service had systems and procedures in place to make referrals to the court of protection should they feel that a person was deprived of their liberty via their care plan. It should be noted that whilst the agency does not have responsibility for making applications under either of these pieces of legislation they had responsibility for ensuring that any decision on the MCA 2005 were complied with. Care staff we spoke with demonstrated understanding of these areas. Care plans looked at showed that consent to care and support was being obtained either from the person themselves or if this was not possible then from a close relative. In the care plans we looked at which mentioned the need for staff to support a person with their food, we saw that people had been involved with decisions about the food they ate and their preferences were clearly set out. We saw a person enjoying their lunch when we visited them in their home.

They told us that the food was delicious and staff discussed menus and meal preparation and made sure the meals they provided suited their taste. Their comments included “The girls are so kind and considerate. They ask me what food I like and although it is written in my care plan they ask me every day. They cook what I want, just the way I want it. Look at this meal, it is so good no wonder I feel so healthy”. The service did not take primary responsibility for ensuring that health care needs were addressed. However, the service required that any changes to people’s condition that were observed by staff were reported immediately to their relative or on call agency staff. We saw records that showed that information from a range of health care professionals had been used to ensure all care and support plans were up to date. Staff told us that if the person who used the service had no close relative then staff would assist them to telephone for an appointment with a relevant health care service.

People we spoke with were very satisfied with the care provided by staff of the service. We were told, “The carers are well trained and so respectful to my (relative)” and “She (relative) does not like strangers in her house but the staff have become more like her friends and she likes that”. People who used the service said “They (staff) have always got a smile on their face, they chat to me and make me feel special”, “I look forward to them calling here, they make me feel good, they are always so pleasant. I call them my lovely ladies” and “They (staff) have become my very dear friends. You can keep your pills and potions, it’s the care that matters, they are fabulous”. The care plans we looked at drew attention to individual needs such as how people communicated and their cultural identity.

Staff spoken with displayed clear knowledge and understanding of people’s diverse needs and their right to live a fulfilling life. We saw from the staff rosters and log book records that people received their care and support from the same carers in the vast majority of occasions. The records showed that the same care staff delivered a person’s care. This meant that they knew the needs and preferences of the person they cared for and would be able to build up a good relationship with them. The registered manager told us that the staff were passionate about supporting people to maximise their potential. She said that when people commenced using the service wherever possible they matched care staff to meet people’s individual needs. She said that she monitored how relationships developed once staff had started working with individuals by way of observations of interactions and responses and where necessary ensured that staff were provided with specialist training to enable them to provide care appropriate to individual need. We observed interactions between staff and people who used the service and noted the relationships were one of mutual trust and rapport. The staff members displayed clear understanding of the people’s life skills and provided them with encouragement and support to enable them to maximise their independence.

The staff members, by their actions and words, instilled confidence in the people and showed awareness of any signs of discomfort and provided quiet reassurances. The staff members fully engaged with people and used appropriate language to provide any information they requested. The staff members were aware of confidentiality issues and told us that all information recorded on file was maintained securely within the main office. Staff told us that people were involved in the daily recording process and if they challenged anything that was written it was discussed and agreement reached about the content of the recording.

We noted that the registered manager had recognised that a breach of confidentiality had recently occurred and had taken appropriate action to deal with the situation. This showed that the service acted quickly to ensure that people’s information was secured stored and staff were fully aware of the policy and procedures in respect of the sharing of information. The care records we looked at were based on people’s personal needs and wishes. Details were recorded of what people were able to do for themselves to enable them to maintain their independence. One person told us “It is very important to me to retain some independence as I want to do as much for myself as possible. These staff know what I can and cannot do for myself and assist me to manage my care in a way that helps me to feel Ok about myself”. Staff told us they felt the service was very caring.

We saw the staff handbook contained the following quote- ‘Resolve to be tender with the young, compassionate with the aged, sympathetic with the struggling and tolerant with the week and the wrong. Sometime in your life you will have been all of these’.

People told us that the care and support they received was tailored to their needs. Comments included “I get the care I need, when I need it, from staff I like. One girl (staff) came here once and I did not like her so I told the manager and she never sent her again”, “The staff are reliable, do anything I ask them to do and they are so thorough” and “Lovely staff, turn up on time, they know what care and support I need and I could not get a better service”. A relative of a person who used the service said “The staff know my (relative) well. They understand dementia and care for (relative) very well. They know just what to do to provide proper care. They are wonderful; I don’t know what we would do without them”. Another relative of a person who used the service told us that their relative had experienced a missed call but the ‘office had sorted it and it had never happened again’. The registered manager told us that prior to a service being provided staff would undertake an assessment of people’s needs, wishes, wants and preferences together with a risk assessment to look at the environment and social risks. She told us that once the assessment had been completed and a care plan drawn up and agreed the person would be introduced to the care team before the commencement of the service. Records showed that once the above process had been completed the care to be provided by staff was very clearly set out. This included information about people’s preferences and individual needs such as times when care staff were to call and if more than one carer was needed to provide the care and support. Staff we spoke with were knowledgeable about the people they supported. They were aware of their preferences and interests as well as their health and support needs. They told us that this enabled them to provide personalised support. Staff told us that they were able to read signs from the people they supported as to their state of mind. For example we were told that signs included lack of eye contact, lack of communication and apathy. We asked staff how they ensured that people received the care they required. The registered manager told us that they had a system in place to spot check the work of individual carers. This involved a senior member of staff observing care staff whilst they were carrying out their duties in people’s homes. This was always done with the agreement of the person who was in receipt of the care. Each person’s care needs were reviewed at least annually and more regularly if there were specific concerns, which we found to be the case in the care plan’s we looked at. One person had commented that they did not like the carer who had called at their home and said this had been quickly addressed. The registered manager said that it was of utmost importance that there was a positive rapport between staff and people who used the service to ensure that the care and support was maximised.

We saw that daily logs were kept and detailed how the person had been supported each day. Our observations of staff practice confirmed it was very person centred. We were advised by the registered manager that the service provided training to embed person centred culture within their practice which included how to record in a person centred way. This would help to ensure that the practice we observed was evidenced on a daily basis. We saw systems were in place for recording and managing compliments and formal complaints. A copy of the complaints procedure was displayed on the notice board in the main office and provided to the people who used the service when the service commenced. Records showed that the policy identified that complaints were to be logged, actions taken and outcomes recorded within the procedure’s timescale. The service had not received a formal complaint within the past twelve months.

People who used the service who we spoke with told us they liked the registered manager Comments included: “She runs a good service”, “She puts the people first” and “A lovely service managed by a lovely lady”. Staff told us that they felt supported and could approach the registered manager at any time for help and advice. They said: “The manager ensures that all the staff work well together as one big team”. A positive culture was evident in the service where people who used the service came first and staff knew and respected people’s right to choose. The service had a whistleblowing policy and records showed this had been drawn to staff’s attention during supervision. The statement of purpose and service user guide were in an easy read format to make it easier for people to understand them. They also held clear details of contacts in respect of compliments, concerns and complaints about the staff or services provided. There were other systems in place for monitoring the quality of the service. There were monthly checks carried out by the registered providers who completed an audit and action plan if any improvement’s were required. These included such things as staff training issues, people’s money, medicines and records.

The registered manager ensured any requirements were actioned. The local authority had completed a recent quality inspection, which was mainly positive, and we saw that the manager had completed the few actions required in a timely manner. The manager showed a commitment to working with other agencies to improve the quality of service for people. The registered manager told us that as it was a small agency she was able to visit the people who used the service at least once a month to discuss their care, look at their care plans and medication records. She told us that annual surveys would also be used to gain people’s perception of the staff and services. This would include questionnaires being sent to people’s relatives and health and social care professionals as appropriate.