Archived: Prestige Nursing Exeter

This service was last inspected in June 2015 and was rated as ‘Good’ overall. We had not received any complaints or safeguarding information since that inspection.

We brought forward this comprehensive inspection because we received concerning information relating to the management and quality of the service. The local authority made us aware that at the end of July 2017 Prestige Nursing Exeter had informed them they were unable to cover approximately half of their care packages due to a lack of staff. This meant that at short notice the local authority had to arrange for around 25 care packages to be covered urgently by alternative care agencies. We then received information relating to concerns about the management of the administration of medicines identified by those agencies. We also received information from two anonymous complainants about the management of the service and two complaints from individuals. The service was placed into a whole home safeguarding process by the local authority and we attended a safeguarding meeting. The local authority suspended further placements to the service until further notice.

From June 2017, there had been a set of circumstances relating to changes in management and staff turnover, including a new manager in June 2017 and staff leaving or on holiday, which had impacted the service’s capacity to effectively cover their 50+ care packages at the end of July 2017. These changes and their management by the provider had meant that there had not been enough staff to meet people’s needs. This had been managed locally in the office initially using their existing staff and other care agencies and then had resulted in the service requesting urgent transfer of some care packages by the local authority permanently to alternative care agencies. During the first week of August some people did not receive a visit and some people received visits that were not their preferred time. Some people complained that they did not know who would be visiting them and they had received care from staff they had not met before.

Therefore, we found there was a failure to maintain adequate staffing levels to meet people’s needs during July and early August 2017 and the provider had failed to ensure sufficient oversight of the Exeter office to prevent this happening. These areas required improvement.

During this inspection on 20 and 21 August 2017 there were 23 people remaining who were receiving personal care support. There were ten care workers supporting these people and we saw completed staff rotas for the next two weeks and received reassurance that actions had been taken to ensure these care packages would be covered and people’s needs met.

We also found there were failings in medication management and administration. Although care workers had received up to date training in medication management, during this inspection on 20 and 21 August 2017 we found medication administration records were unclear and incomplete and did not describe to staff how to meet people’s medication needs. This meant people could not be sure they would receive their medication correctly at the right time. We also found two people’s MARS in their own homes contained gaps in administration recording. Although there were good medication assessment forms completed for individuals receiving support with medication, these were only kept in the office and not easily available for care staff to refer to. For example, we saw that one person required prompting with their medication but there was no information in the person’s care plan held in their home as to where medication was stored or in what format or how the person took it. The manager told us the medication audit was usually carried out monthly but this had not been completed since April 2017. We saw that where people had repeatedly refused or did not require medications, this had not been followed up to ensure they were receiving medication which could be important for their on-going health and welfare.

Therefore, we found there was a failure to maintain comprehensive medication administration records which put people at risk of not receiving their medication correctly. We also found the provider had not ensured that the weekly compliance report had identified these failings. These areas required improvement.

During this inspection we saw that the provider and manager had taken action to address this issue which was brought to their attention during the safeguarding process. A medication audit had been commenced and was nearly complete. This had also found omissions in recording by various care workers and lack of comprehensive medication information available to staff in people’s homes. Actions had been taken to address these findings when we carried out our inspection.

People told us they were happy with the care Prestige provided. They were aware of the difficulties the agency experienced with staffing at the beginning of August 2017, but they had experienced no problems prior to that period, and they told us things were running smoothly. Comments included, “I get a weekly rota and then those staff come. They’re all lovely, I’m happy and I don’t have any problems”, “The worst thing was when no-one rang me about a missed visit [in the first week of August] but since then it has been fine. The [care worker] who comes to me is excellent, very quick, intuitive and tremendous” and “I’m happy with the care. Generally speaking things have worked out ok. [Care worker’s name] is my buddy, they know what they are doing and we get on well.” Another person’s advocate told us they had seen the Prestige care workers over the years and they were always kind and caring and they had never missed a call. They added that staff had seemed unsettled with all the changes in the office but things seemed better now.

The management team told us they were committed to providing a good quality, effective service to people going forward. There was now good support from head office. The management team told us they could see how the lack of staff and capacity to meet people’s care packages had happened and felt it was an isolated incident. They had devised an action plan and were addressing the issues relating to staffing and medicines which included a more formal new manager induction process so that potential issues could be identified sooner in the future. The manager had met with each remaining staff member to ensure they were aware of the situation, and to ensure the staff felt supported and committed to Prestige. A further group staff meeting was booked.

People told us they felt able to raise any issues with the office management team but had not felt the need to. There was a communication book in the office and telephone calls were inputted into individuals files on the computer system showing they were actioned. We received two separate anonymous comments. They related to management and employment issues at the time of lack of staff capacity. Where one area of poor care affecting one person had been identified in one of these comments, the service had already identified this and taken action to speak to the individual care worker during supervision and refresh their training.

Care workers were described as “lovely”, “kind” and “caring” and their privacy and dignity was respected. Where some people preferred female carers for example, this had happened. During the period of lack of staff some people had received care from a male care worker for one or two visits. They said this had not been a problem and we saw alerts were added to people’s computer files and this information was in their care plans. Care plans in people’s homes and in the office reflected the care people required. They were personalised and detailed about people’s preferences and what tasks they liked carried out and when. This ensured when care workers visited people they had the information they needed to provide person centred care. People told us the service was flexible and made adjustments to accommodate their wishes and changing needs. For example, one person rang weekly to say what care they would like depending on what they were doing that week. Where any concerns were raised about a person’s health or well-being prompt action was taken to make sure they received the support and treatment needed. For example, one person told us how fantastic the care worker had been when they had been unwell, ensuring they got the treatment they needed. Another person had been identified as needing further assessment by their care package commissioner for a possible increase in their visits.

People had been involved in discussing their care and telephone quality assurance calls and spot checks had happened regularly. There were quality assurance systems which monitored standards and ensured any shortfalls were addressed. Although this had failed relating to medication management, all other audits were up to date. This included staff training and supervision, care plan and risk assessment reviews and the provider’s annual compliance audit. The service had not received any formal complaints over the last 12 months from people using the service; people knew how to complain using the Prestige complaints policy.

At present, people were receiving care from a small group of care workers who they knew. The manager said that going forward when there were more clients they would devise ‘staff runs’ again. This meant that individual staff would have a more regular rot

The agency provided a service for twenty three people, supported by twenty staff. We found that the agency had been through a period of change and many of the people who used the agency and the staff were new.

People said they had a 'good rapport with the manager' which gave confidence in knowing who to contact if there were concerns. People said communication between themselves and the staff was 'very good'. One person said 'if they didn't do what I needed, I would tell them'.

Care and support was personalised and took into account individual preferences and choice. We examined six care plans written in the first person. Plans described what the person wished to achieve from the service and what was important to them.

Wherever possible the same staff were provided to people which provided continuity of care.

Staff were knowledgeable in their understanding of hygiene which protected people from risk of infection.

We found inconsistency in medication records held in people's homes which meant that people were not properly protected from risk. We could not be confident that medicines were handled appropriately.

The provider had systems to monitor the quality of the service provided.

We spoke with five people and three relatives and asked them about the care and treatment provided, and we looked at four people's care records. Everyone we spoke with reported improvements in staff time keeping and reliability and in communication with the Exeter office. One person said' I feel very lucky, they are very good, conscientious, and I couldn't do without them'. A relative said 'It's a lot more efficient, all carers wear their uniform and their name badges and arrive on time. I feel totally confident to leave mum now'.

We spoke to six staff and looked at three staff files. The agency had reduced the home care workload and showed us the improvements made in relation to people and staff. This included seeking regular feedback from people and their relatives, and increased staff training. It also included improved monitoring of standards of care through regular supervision of staff and 'spot checks'. Where people raised concerns, we saw their concerns were listened to, and addressed. We found improved standards of record keeping in people's homes and at the agency's office.

We spoke with one person and four relatives and asked them about their care and looked at five people's care records. Four of the five people we spoke with reported improvements over the past few weeks in terms of staff timekeeping and reliability. One person said 'I'm happy with the carers; they arrived on time so I could go out today'. A relative said 'care from the carers is absolutely fantastic' but another relative said 'I am less than satisfied'.

We spoke to eight staff and looked at six staff files. We found the agency had a reduced workload so were able to manage with existing staff and were recruiting more staff. We saw a range of improvements had been implemented in relation to quality monitoring. This included seeking regular feedback from people and completing supervision and 'spot checks' with staff. We found the provider was compliant with the two outcomes we inspected.

Since our last inspection, we have received an action plan from Prestige which detailed further improvements in relation to the seven outstanding compliance actions. These will be followed up at a further inspection.

Two people said staff were very pleasant and reliable. However, two people and three relatives identified a number of concerns about the service. One relative told us how a vulnerable person who needed three visits each day to support them to eat and drink was left alone all day. A second person was admitted to a nursing home for five nights as the agency could not provide skilled staff to meet their needs. A third person needed two care workers to support them but we were told sometimes, only one care worker visited. Their relative said 'We are really disappointed, we can't go on because X is suffering, we have got to think about her and her wellbeing.'

We identified a number of concerns about poor communication systems and low staffing levels. We were told people did not know which staff were visiting, how staff were often late and left early. One relative said 'there is no one is in charge at the office'. Five people said when they left messages, they often weren't responded to or they experienced long delays. The systems in place to identify and manage risk to people were not working effectively as the provider had not taken swift action in response to incidents and complaints to prevent ongoing risks to people. This meant several people did not receive the care they needed.