NR Care Head Office

NR Care Head Office is a domiciliary care service. They provide personal care and support to people living in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection the service was providing a regulated activity to 20 people.

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

People felt safe when staff supported them. Staff knew how to report concerns and keep people safe from harm.

Although staff supported people safely with their medicines, records were not always thorough. There was not always full guidance in place on how and when topical creams should be administered. Allergies were not always written on the Medicines Administration Records (MARs), which meant that unfamiliar staff may not always have this information immediately available when administering medicines. However, these risks were mitigated due to the person having a regular member of staff who knew them well, administering medicines.

Risks to people were planned for and there was guidance in place for staff to manage these.

Staff were recruited safely and there were enough staff to cover people’s care visits.

Staff received training in areas relevant to their role, and where needed, related to specific people’s needs.

Staff used Personal Protective Equipment (PPE) as required by current guidelines and followed good infection control practices to reduce the risk of the spread of infection, including COVID-19.

People’s needs had been assessed thoroughly before the service agreed to deliver care so they could ensure they could meet these needs. Care plans were person-centred, with guidance for staff on how to meet their needs, including physical and mental health, family lives and interests.

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.

Staff asked for consent before delivering care, and understood people’s needs around making decisions, but further work was required around care planning records relating to people’s mental capacity. We have made a recommendation in this area.

People were, in the main, supported by a consistent group of staff who knew them well. Staff supported people in a caring way and involved them in decisions relating to their care.

Staff were supported by the service, and felt involved. Quality assurance systems were in place which identified areas for improvement, which were then acted upon. The provider recognised areas where further work was still required and had made plans for ongoing improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update:

The last rating for this service was Requires Improvement (published January 2020) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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.

NR Care Head Office is a domiciliary care service. They provide personal care and support to people living in their own homes. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of our inspection the service was providing a regulated activity to 42 people.

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

People were not receiving a good service as quality monitoring systems were still not effective in identifying and improving quality. Whilst some improvements had been made in some areas, in others the service had deteriorated. Actions to make improvements had not been carried out in a timely way, issues identified at our previous inspection were still apparent at this latest inspection. People and their relatives had not always been fully engaged and consulted on the service provided. Changes to people’s care, such as changes to rotas or timing of calls were not always communicated.

Risks to people had not been identified or thoroughly assessed, where risk assessments were in place some were confusing and not accurate. The lack of robust risk assessments meant there was potential that risks to people would not be identified and/or responded to appropriately. People were being supported, in some cases, with complex health care needs. Additional training and support for staff in how to meet these needs had not always been identified. This meant it was possible that staff would not be able to support people with these tasks in a safe manner. People did not always receive their medicines safely. Staff did not always administer medicines as prescribed. Information about people’s medicines and their support needs was not clear and increased the risk of a medicine administration error. Most people were supported by a consistent group of staff, although there some people told us there were occasions, for example on weekends, when they were supported by unfamiliar staff. Where incidents had occurred in the service these were reported and reviewed by the registered manager. However, we found the analysis of incidents could be strengthened.

We have made a recommendation that the provider reviews how it delivers training and supports staff to meet the individual needs of people using the service. This was because the management team had not always identified where staff would benefit from additional training and support. Staff also gave mixed feedback on the effectiveness of the training.

People were not supported to have maximum choice and control of their lives. The policies and systems in the service did not support this practice. We have made a recommendation for the provider to seek advice from a reputable source on implementing and embedding the Mental Capacity Act within its practice. This was because assessments of people’s capacity to consent to individual decisions had not always been completed appropriately by staff. In some instances, staff were seeking consent from other parties on behalf of the person using the service without checking they had the legal authority to provide it.

We have made a recommendation that the provider review their systems and processes to help ensure people are respected and their equality needs fully considered. This was because whilst people told us staff providing day to day support in their homes were kind and caring, staff in the office did not always communicate effectively and listen to them. We also found the service had not fully considered people’s equality characteristics when implementing any changes.

People’s needs were not holistically assessed. Assessments had not always taken in to account the range and complexity of some people’s needs. People’s care plans did not provide detailed and person-centred information regarding their care. The service was supporting some people at the end of their life but end of life care plans were not in place. Staff had worked with health and social care professionals to gather information about people’s care needs. However, we found this information was not always reviewed and used effectively to help plan people’s care and support

Staff had enough time to provide the support needed. Where people were assisted with their meals and drinks this was done in line with their needs and preferences. People told us staff helped them appropriately with their meals when required and ensured they had drinks. People were protected from the risk of infection by staff who understood infection control procedures. Where safeguarding concerns had been raised people had been supported by staff and appropriate actions had been taken in response. People’s dignity and independence were respected. There were opportunities for people to discuss the support provided to them. People’s concerns were listened to and action was taken in response.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 28 November 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, enough improvement had not been made and the provider was still in breach of regulations. The service remains requires improvement. This means the service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to safe care and treatment and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We last inspected the service in August 2017 where five breaches to the regulations were found. At this inspection we found four of the previous breaches remained. We have also made three recommendations to help drive improvement.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults, some of whom were living with dementia and had physical disabilities.

At the time of the inspection NR Care Head office was supporting 105 people in their own homes. NR Care had an accessible office where staff were available during office hours. A managed out of hours on call service was also available to support staff and people in receipt of the service.

Not everyone using NR Care received a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

NR Care had 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 about to go on an extended period of leave and a replacement manager had been recruited to cover their absence.

We had previously noted the service had not acquired consent from people to share information with other professionals. The service had developed and acquired this consent at this inspection but had not taken the steps required to ensure all consent was acquired in line with the principles of the Mental Capacity Act. This included assessment to determine someone’s capacity to give consent when this was in doubt.

People were mostly supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible; the policies and systems in the service did not always support this practice. This meant that appropriate assessment and decision-making procedures had not routinely been followed.

It was noted at the last inspection the service was not managing complaints in line with the regulation. This was still the case and we found the provider had not developed a system to manage complaints in line with their own procedure. This meant that when complaints were received they were not routinely; responded to, investigated and managed as the service’s policy dictated.

Notifications for certain incidents including potential safeguarding concerns are required to be sent to the CQC. At this inspection we saw the provider was reporting incidents to the Local Authority safeguarding team in line with their guidance. Where the safeguarding team had notified them, an incident was not being investigated further they had failed to notify the CQC. Notifications should be made to both the safeguarding team and the CQC in line with their associated guidance.

At the last inspection we found that there was not a developed system of quality audit. We found improvements had been made in this area and some audit and reviews had improved. However, some consisted of only the simple collation of figures and basic detail. The analysis of this information required further development to drive improvements and prevent reoccurrences if possible.

At this inspection we have made recommendations to support the provider in the area of contingency planning to ensure the risks are managed to prevent a major incident; also in care planning areas around end of life care and monitoring people’s weight to ensure people receive a good standard of support in these areas.

The previous inspection had found concerns around poor staff performance which had not been investigated or managed appropriately. This had left some people at risk of a poor service. We found action had been taken in this area and feedback was more actively sought and acted upon if concerns were noted.

At this inspection we found assessments of the risks to some people had not been updated or reviewed as risks had changed. We found where risks had been identified action had not routinely been recorded to mitigate risks. This included risks to people’s skin from pressure ulcers and following accidents including falls. However, this was only the case in the office records. In the homes of the people we visited we found risks were recorded appropriately and staff took the required action to reduce and manage any associated risks

When we visited people in their homes and reviewed medicines we saw these were managed safely and people received their medicines as required when supported by the service.

The service was supporting some people with complex needs who were supported by equipment to keep them safe. Staff told us they received training in using this equipment. The service had recently recruited a nurse who would be responsible for safety of delivery of any clinical tasks and staff competence in this area.

People told us staff treated them with respect and they mostly received a good service. Staff were well trained and competent in their role.

Staff were recruited safely and the appropriate checks were made to ensure people were suitable for the role for which they were recruited.

You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 6 and 7 July 2017 and was announced.

NR Care provides a domiciliary care service in people’s own homes. The service was supporting 130 people with their personal care needs at the time of this inspection. NR Care supports older people, some of whom are living with different forms of dementia, people with physical disabilities and people with mental health needs.

The registered manager left NR Care a month before we inspected the service. There was an acting manager in place who was applying to become the 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The nominated individual and provider were involved in the day to day running of the service. A nominated individual also has a legal responsibility for the service to meet the legal requirements and regulations.

At this inspection we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the end of this report.

People were not always protected from the risk of harm or abuse. A person had made an allegation about a member of staff harming them, but the appropriate processes were not followed. No investigation took place to find out what had happened, and to ensure people were protected against this risk in the future.

People were supported by staff who sought people’s consent before supporting them. However, the service was contacting health and social care professionals on their behalf without obtaining people’s consent to do this. Staff were also making a certain decision on behalf of a person and restricting their freedom, without following the guidelines of the Mental Capacity Act 2005.

Complaints and concerns were not managed in an appropriate way to respond, address, and investigate what had happened and try and prevent it from happening again.

Systems were either not in place or the monitoring of the quality of the care and service provided was not robust. Audits were either not taking place or they were not effective in identifying where improvements were required. When issues had been identified there was no evidence to demonstrate that action had been taken to address these issues, to prevent them from happening again.

The nominated individual and the provider did not have a robust overview about the quality of the service provided and where the service needed to make improvements.

The CQC was not informed about a potential safeguarding event, which by law, the then registered manager or the nominated individual should have notified us about.

There were no effective systems in place for the office staff to follow if concerns were raised about staff practice, when they were supporting people. We found examples of when people had informed the service about potential concerns relating to the staff who supported them. Appropriate action was not taken to investigate, monitor staff, and address staff practices.

Staff knew how to identify if a person was experiencing harm or abuse in some way and knew to report this to the manager. However, staff did not know of the outside agencies they could also their report concerns to.

Plans to manage the risks which people faced were not always robust. These risks were not always identified and explored sufficiently when the service assessed people’s needs. However, people told us that they felt safe when they received support from staff.

Staff had a thorough induction to their work, had regular training, and supervisions. However, the training provided did not always take into account people’s specific individual needs. There were limited checks to evaluate the competency of staff, to ensure they met people’s needs safely and effectively.

People told us that they received appropriate support with their food and drinks. However, we had concerns about one person who received support with their food and drinks, which we told the nominated individual about.

Staff were caring and kind to the people they supported. People also told us that staff treated them in a way which promoted their dignity and staff respected their privacy. People had formed positive relationships with staff who supported them and they had confidence in the staff’s abilities.

However, this was not consistently the case. We were told by some people who used the service and their relatives about some examples of staff practice which were not caring. The way the service managed these situations did not always promote a caring culture at the service.

People told us that they saw regular staff, at times they were happy with, and they knew when and which members of staff would be visiting them on a regular basis. People rarely experienced late calls. All the people we spoke with said they would recommend the service to others.

People spoke positively about staff engaging with them, chatting, and involving them in their care. Staff were aware of the risk of people being socially isolated. The service was making plans to support these people in the future.