Archived: Bespoke Care At Home

Bespoke Care at Home is a domiciliary care agency. The service delivers personal care to people with mental health needs, people living with learning disabilities, autistic people and people with dementia. At the time of the inspection there were 63 people who received the regulated activities.

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

Most people said they felt safe from harm, but we found unsafe work practices that amounted to abuse. A person told us, “One of the carers was showing another carer what to do, and when [the staff] left the house, they left my door wide open. That’s not safe. When I complained, they just had to apologise”.

The provider used illegal restrictive practices and was not aware of their responsibility to identify and report potential abuse. The provider did not do all that was reasonably practicable to mitigate risks to people’s health and safety. Systems in place to assess the deployment of staff were ineffective and unsafe recruitment practices meant the provider did not always protect people from unsuitable staff. Medicines practices were safe. We have made a recommendation relating to infection control.

The provider did not ensure the design and delivery of care and support was delivered in line with current evidence-based guidance, standards, best practice, legislation. The provider did not make sure all staff were appropriately skilled, knowledgeable, and qualified to ensure people’s care and support needs could be met. The provider worked with external agencies, we saw some good examples but this was not consistent. People’s nutritional needs were met.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People were not always treated with dignity and respect. Their preferences for care and support were not always met. People said they were involved in making decisions about care and support, but we found actions taken, and outcomes achieved were inconsistent. People said staff knew them well and electronic care records provided more information about people’s lives.

The provider did not always meet the care and support needs of people with learning disabilities and people with dementia. People had expressed dissatisfaction with call times and duration of care call visits. We found the provider’s complaints systems were ineffective as the provider was unable to appropriately address them.

Quality assurance systems used to assess, monitor and improve service delivery were inadequate. The nominated individual and senior management did not have all the necessary skills and knowledge to become compliant with the regulations and associated legalisations.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support:

People were not supported to have maximum choice and control of their lives. Not all staff had not received appropriate training to support autistic people, people with learning disabilities and people with dementia. Staff failed to design and deliver care and support relevant to their learning disability needs and protected characteristics as outlined under the Equality Act 2010.

Right Care:

People were not always treated with dignity and respect. The provider did not have enough appropriately skilled and knowledgeable staff to meet people’s individual needs. Especially when they were communicating a need when distressed or anxious.

Right Culture:

People were supported by staff who did not always understand best practice in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. This meant people did not always receive compassionate and empowering care that was tailored to their needs.

Rating at last inspection and update

The last rating for this service was inadequate (published 1 October 2022) and there were breaches of regulations. The provider sent us action plans on a monthly basis, to show what work they had undertaken to become compliant with the regulations.

At this inspection we found the actions taken by the provider was not enough to become compliant with the regulations and therefore, they remained rated inadequate.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has remained inadequate. 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 Bespoke Care at Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified continued breaches in relation to person-centred care, dignity and respect, safe care and treatment, safeguarding service users from abuse and improper treatment, receiving and acting on complaints, good governance, staffing, fit and proper persons employed, duty of candour and notifying the Commission of notifiable incidents. We found a new breach in relation to need for consent.

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

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Bespoke Care At Home Limited is a domiciliary care agency. It provides personal care to people living in their own homes. This can include specific hours of required support or live in carers to help promote the person's independence and wellbeing. 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 personal care to 161 people.

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

The registered person did not operate effective quality assurance systems to oversee the service. These systems did not ensure compliance with the fundamental standards and identifying when the fundamental standards were not met.

The registered person did not ensure consistent actions were taken to reduce the risks where possible and the plans were not in place to minimise those risks. Effective recruitment processes were not in place to ensure, as far as possible, that people were protected from staff being employed who were not suitable. The management of medicines was not always safe. Not all staff were up to date with, or had received, their competency checks and mandatory training. We did not have evidence the management team kept their knowledge and competencies checked and up to date.

When incidents or accidents happened, it was not always clear that it was fully investigated, and if lessons were learnt. The registered person did not ensure that clear and consistent records were kept for people who use the service and the service management. The registered person did not inform us about notifiable incidents in a timely manner.

Staffing levels did not always support people to stay safe and well. The management team scheduled the visits however timings and length of visits were managed poorly. People and relatives were not consistently informed about the changes to their visits or the staff being late. People and relatives told us the times of visits were not kept according to the care plan. People and relatives told us the staff did not always show kind, caring and friendly practice and did not always uphold people's privacy or respond in a way that maintained people's dignity.

People, their families and other people that mattered were involved in the planning of their care. However, the care plans did not contain information specific to people’s needs and how to manage any conditions they had. Staff did not have much detailed guidance for them to follow when supporting people with complex needs. Staff were not always following the care plan to provide the right support to people.

We received mixed feedback from people and relatives about feeling safe when staff were supporting them. The registered person did not ensure their safeguarding systems were operated effectively to investigate and follow the provider's procedure after becoming aware of an allegation of abuse. Most of the staff were not up-to-date with their safeguarding training. Not all people and relatives felt they could approach the management and staff with any concerns and felt that communication had to be improved. When people and relatives raised complaints, these were not consistently responded to, acknowledged, or improvements made. We judged people were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always supported this practice.

We have made a recommendation about seeking guidance from a reputable source to ensure the MCA legal framework and provider’s responsibilities to people and their decisions were followed accordingly.

We have made a recommendation about seeking guidance from a reputable source to ensure the principles of the Accessible Information Standard were met.

Most of the staff members felt staffing levels were sufficient to do their job safely and effectively. However, they said they had to visit a number of people so sometimes this affected the length of visits. The management team appreciated staff contributions and efforts during pandemic to ensure people received the care and support. Staff felt they could approach the management team and office staff. However, they also said the communication could be improved.

The management team was working with the local authority to investigate ongoing safeguarding cases. There was an emergency plan in place to respond to unexpected events. Staff had ongoing support via regular supervision and appraisals. They felt supported and maintained overall teamwork.

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 good (published 20 March 2019).

Why we inspected

The inspection was prompted in part due to concerns received about the management of people’s care and visits, medicine management, quality of care and management of the service. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to quality assurance; risk management; notification of incidents; safeguarding management; record keeping; effective and person-centred care planning; management of medicine; staff training and competence and recruitment; staff deployment. We have made a recommendation about meeting the Accessible Information Standard and Mental Capacity Act legal framework.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

This is the single location within the provider’s current registration. The office is in the central business district of Burnham. Areas covered included Maidenhead, Slough, Windsor, Burnham, Marlow, Cookham and Dedworth. At the time of our inspection, 65 people used the service and there were 53 staff.

People’s experience of using this service:

Risks to people’s well-being were assessed, recorded and updated when people’s needs changed. Training records showed that people were supported by skilled staff that had ongoing training relevant to their roles. The service was a family run company which contributed to creating a personal touch and a strong, visible person-centred approach. The provider had effective systems to manage complaints. Staff said the provider successfully maintained an open and transparent culture which contributed to staff work satisfaction and in turn the staff delivering good care for people

Rating at last inspection:

This was our first inspection of the service since the registration changed in January 2018.

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received. We inspect newly-registered services within 12 months of registration.

Follow up:

We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

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