Archived: Teonfa Care Group (South West)

Teonfa Care Group (South West), hereafter referred to as Teonfa is a domiciliary care agency that was providing support to 47 people living in their own homes in Plymouth and North Devon at the time of the inspection.

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

The service was not safe, and people were placed at risk of avoidable harm. This inspection resulted in the identification of significant and immediate risks. We shared our concerns with the relevant local authorities who acted to provide extensive support and to ensure people were receiving safe care.

There were not enough staff to meet the care needs of people. Visits were being missed, or shortened, or were so late that people weren’t getting their continence, nutrition, hydration and personal care needs met. Some people, who had been assessed by a professional as needing two care staff to support them to move safely, were being repeatedly supported by one staff member. This placed the person at risk of a fall or injury and was also unsafe for care staff who were providing care alone.

Medicines were not managed safely; some people were given too much of a medicine and some people had missed doses of medicines. Staff were not confident or competent at administering medicines.

The provider was unable to demonstrate that recruitment of staff was safe. The provider could not find records relating to recruitment. .

Risks to people were not assessed and risks were not mitigated to reduce the potential for harm.

There was insufficient evidence to show staff had training to meet the needs of all the people they supported. Health concerns were not flagged up promptly to health professionals. People did not receive holistic assessments of their needs. There was not a system in place to ensure staff knew what people’s needs were, and how to meet them

Staff knew about asking for consent when delivering care. We saw evidence of restrictive practices being used by care staff and endorsed by the leadership in the service. 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 told us care staff were kind and caring but unreliable. People said they did not feel listened to by office staff and were not part of deciding how their care was going to be provided.

Over half of people we asked to see care plans for did not have one in place. The service was not person focussed and let people down in the provision of their care through a lack of consideration for their welfare and preferences. There was a complaints log, but it only contained one complaint, issues that families told us about had not been captured or actioned. The service had not considered the accessible information standard.

There were widespread failures in the leadership of the service. The registered manager had recently left, and the provider and interim manager did not understand the systems and were struggling to run the service. There was no visible leader in the service that knew how the service was run, how to operate effective systems to keep people safe or what people’s needs were. On the first day of our inspection we arrived and asked for the provider or interim manager to attend. They told us they were unable to come to the service to meet with us. They were present for the remainder of the inspection.

Care documents were incomplete, out of date or inaccurate and many records requested were missing. The service was unable to keep people safe, support staff appropriately, mitigate risks, or provide a basic level of care when we went to inspect.

We found breaches in regulations relating to safe care and treatment, staffing, consent, duty of candour, recruitment, governance, complaints, making notifications, person centred care, and safeguarding. We also made one recommendation.

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:

This service was registered with us on 18 March 2019 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about care visits being missed, staffing and medicines.

We have found evidence that the provider needs to make improvements across the whole service. Please see the safe, effective, caring, responsive, and well-led sections of this full report.

Actions taken by the provider at the time of the inspection to mitigate risks were not adequate or effective. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to staffing, complaints, safeguarding, safe care and treatment, good governance, person centred care, making notifications to the CQC, duty of candour, recruitment, and dignity and respect at this inspection.

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

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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 of 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.