Archived: Faith IN ME Home Care

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During our assessment of this key question, we identified a breach of regulations in relation to the management and oversight of the service. When concerns were raised, managers did not review these with a view to driving improvement in the service. Systems to manage rotas were ineffective leading to a lack of consistency in people’s visit times. People, relatives and some staff told us managers were unprofessional and boundaries and responsibilities were not clear.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Concerns had been raised prior to the inspection about the values and professional conduct of the provider/owner and another member of staff. At the time of the assessment visit there was an ongoing safeguarding investigation. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. Staff and relatives told us managers were sometimes unprofessional and boundaries were unclear. For example, we were told of occasions when the owner/ manager had discussed members of staff with other staff and relatives.

At a recent visit from the local authority quality team the owner/provider had been informed they did not hold the necessary qualification to deliver training. They were unaware of this requirement. This meant new staff may not have received quality training before starting work. The manager had not recognised when there was a risk of closed cultures developing. When staff who were in a close personal relationship worked together with no other staff present this risk had not been considered. No steps had been taken to minimise the risks. The service PIR stated: ‘We implement a robust interview process and ensure we gain all information required: DBS, references, employment history.’ As outlined in safe we identified gaps in pre-employment checks, including those for senior staff. One member of staff’s reference stated they had ‘overstepped boundaries with clients.’ This had not been addressed at interview or any action put in place to monitor the risk. Allegations had been made against a member of staff in relation to their professionalism amounting to possible gross misconduct. No action had been taken to mitigate any potential risk to people.

Supervisions and spot checks had not been regularly held until shortly before the site visit. This meant there were few opportunities for staff to highlight areas of concern. A new care manager had started to address this and staff told us recent spot checks had been completed. Records confirmed this. However shortly after the first site visit this member of staff left the organisation and the spot checks stopped being carried out. A staff meeting was held on 8 March 2024. Prior to this there had not been a staff meeting recorded since July 2023. This meant opportunities to raise issues had been further limited. There was a policy in place called ‘Raising Concerns, Freedom to Speak up and Whistle-Blowing.’ This outlined how staff could raise any concerns and included local contact details. It stated Faith IN ME would have a Freedom to Speak Up Guardian who could support staff to speak up if needed. There was no information about who this person was.

There was no complaints log in place and the owner/provider told us no complaints had been received. However, four people and/or relatives told us they had raised complaints.

Staff told us they had valued the flexibility their roles gave them which allowed them to fulfil any caring responsibilities they had at home. However, staffing pressures had meant they were often put on the rota outside of their agreed hours. Agreements made about their working arrangements when they first joined the company, had not been honoured.

Staff who had recently left the organisation told us processes in relation to taxes and pensions had not been completed in a timely manner.

Systems to audit various aspects of the service were not robust. There were gaps in the systems in place to monitor the quality and safety of the service. For example, there was no system to monitor accidents and incidents. No analysis of accidents and incidents had been carried out to highlight any patterns or trends. A recent review of care plans had identified a number of gaps and areas for improvement. For example, there were a number of risk assessments which were overdue for review. Systems to ensure people were kept up to date when visits were delayed were not robust. Staff were unsure what constituted a ‘late’ visit. There was no clear process in place for staff to follow when running late. Scheduled call times were inconsistent. For example, one person had a scheduled visit for 7.30 am. Records for the period 1 February until 9th February 2024 (not including 4 February, no records seen) showed only one day when the visit had been at this time. On one occasion the visit had been half an hour early. On every other day the visit had been late. On the 1st, 5th, 6th and 7th February 2024 the visit had been over an hour late which was outside of the range identified by the provider as an acceptable margin of lateness. We saw staff rotas where visits overlapped so staff were scheduled to start a visit before the previous one had finished. Audits and monitoring of visit times had failed to identify the inconsistent visit times as an area for improvement.

At the time of the first site visit a care manger had been employed to oversee the day to day running of the service. The owner/provider told us they would be taking a step back from these duties and senior positions had been created to improve oversight of care planning, auditing and rota management. At the time of the second site visit the new care manager was no longer working at the service and the owner/provider was again overseeing the day to day running supported by a deputy manager. Staffing pressures meant the owner/provider and deputy manager sometimes needed to provide care. This impacted on the time available to complete managerial tasks. Despite the difficulties the service was having meeting people’s needs they were continuing to advertise for work. The deputy manager told us they would take the adverts down. Following the visit the owner/provider told us they were scaling back the business. Staff told us rota management was poor and they sometimes rearranged their rotas in order to meet people’s needs and preferences. We saw evidence of visit plans where there was no travel time between visits, visit times overlapped and occasions when staff had been required to do upward of 20 visits in one day.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.