All inspections: Nightingale Homecare and Community Support Services Ltd

The inspection visit took place at the service’s office on 29 and 30 July 2015. On both days we visited people who used the service in their own homes.

Nightingale Homecare and Community Support Services Ltd are registered to provide personal care to people living in their own homes in the community. They provide care and support to a wide range of people including, older people, people living with dementia, learning disabilities and mental health needs. The support hours varied from 24 hour support to one to four calls a day, with some people requiring two members of staff at each call.

The service also provided care and support through the supported living scheme. These people lived in shared accommodation such as two/three bedroom houses where they shared communal areas with other people. Staff also supported people with their personal care who lived in extra care units, in purpose built accommodation. Each person had a tenancy agreement and rented their accommodation.

At the time of the inspection 109 older people were receiving care and support in the community, 59 in the extra care housing units and 33 people in the supported living accommodation.

The service’s office is based in a business park on the outskirts of Folkestone and offers support and care to people in Folkestone, Hythe, Dover, Deal and surrounding areas.

The previous inspection of this service was carried out in February 2015. At this inspection we found that the provider was in breach of three regulations, safe care and treatment, person centred care and good governance. The provider had sent an action plan to CQC in March 2015 with timescales as to when the service would be compliant with the regulations.

At this inspection the plan had not been fully actioned by the provider and the three breaches of the regulations issued at the previous inspection in February 2015 had not been met. The service continued to be in breach of three regulations, safe care and treatment, person centred care and good governance. We have started the process of taking enforcement action against the provider.

The service had improved in several areas, such as continuity of staff, communication with people, and supporting staff.

There was no registered manager in post. The registered manager had recently resigned from the position. 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 and associated Regulations about how the service is run. The provider told us that a new manager had been appointed who was in the process of applying to CQC to become the registered manager. There was a branch manager in post who dealt with the day to day running of the service and supported the inspectors with the inspection.

Risks associated with people’s care had been identified, but there was not always sufficient guidance in place for staff to keep people safe.

There was a lack of risk assessments in place to ensure that people received their medicine safely. Medicines were not listed or recorded safely so it was not clear what medicines people were taking. Some medicine records were not clear or accurate.

Everyone using the service had a care plan in place; however these varied in detail to show how people’s needs were being met. A new system of care planning covering the assessment process, was being introduced, which was due to be completed in June 2015 but at the time of the inspection there was less than half of the 109 older people living in the community who had the new care plan in place. Therefore some people’s care plans were not up to date and did not have all of the personalised information staff needed to make sure people received the care they needed, in line with their choices and preferences. There was also a lack of information in the care plans for staff to support and monitor people living with medical conditions such as diabetes.

Staff understood how to support people to make decisions and consent to care and support, however mental capacity assessments were not always completed. Staff had received training on the Mental Capacity Act 2005. The Mental Capacity Act provides the legal framework to assess people’s capacity to make certain decisions, at a certain time.

Records were stored safely but were not always accurate. Some medicine records were hand written and not double checked to make sure the correct medicines had been recorded. Care plans and risk assessments were not consistently signed and dated by the staff who had completed them.

People were supported with their nutritional needs. People told us that they chose what they wanted to eat. Staff prepared meals and made sure people had enough to drink.

There was enough staff employed to give people the care and support that they needed. Staff had received training in how to keep people safe and demonstrated a good understanding of what constituted abuse and how to report any concerns. Accidents and incidents were reported and action taken to reduce the risk of further occurrences.

New staff had induction training which included shadowing experienced staff, until staff were competent to work on their own. There was an ongoing training programme in place. Staff had a range of training specific to their role, but there was a lack of specialised training being provided such as, learning disability and epilepsy.

Staff had regular one to one meetings with a senior member of staff. At these meetings they had the opportunity to discuss any issues or concerns. Staff competencies were being ‘spot checked’ to make sure they were caring and supporting people safely.

People were treated with respect and their privacy and dignity was maintained. People we visited told us the staff were kind and respectful. They told us that staff listened to what they wanted and always asked if there was anything else they needed before they left. Families also told us that the staff had a good relationship with their relatives and knew their daily routines and how they wanted their care to be delivered.

People and their relatives were confident to raise concerns and complaints about the service. Complaints were logged and responses given explaining what action had been taken to address the issues raised.

There was a lack of oversight and scrutiny to monitor, support and improve the service. The timescales within the action plan were not met, and the provider remained in breach of the regulations. The provider was open and transparent and acknowledged that the action plan had not been completed; therefore not all of the required improvements had been achieved in the agreed timescales.

Staff said they understood their role and responsibilities but due to the changes in the management structure of the service they were unsure who was responsible for the different areas of the organisation.

The service had systems in place to audit and monitor the quality of service but there was a lack of evidence to show how the results of these checks had been actioned to continuously improve the service.

The provider had made sure that people were able to feed back about the quality of the service. Telephone and quality assurance visits had been carried out to ask if people were satisfied with the service. People confirmed that this process had taken place and at the time of the inspection everyone we spoke with or visited was satisfied with the service. However, feedback had not been sought from a wide range of stakeholders such as staff, visiting professionals and professional bodies to ensure continuous improvement of the service was based on everyone’s views.

We found three ongoing breaches and two additional breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

The inspection visit took place at the service’s office on 26 February 2015. On the 27 February 2015 we visited people who used the service in their own homes.

Nightingale Homecare and Community Support Services Ltd are registered to provide personal care to people living in their own homes in the community. The support hours varied from one to four calls a day, with some people requiring two members of staff at each call. The service office is based in a business park on the outskirts of Folkestone. The service offer support and care to people in Folkestone, Hythe, Dover, Deal and surrounding areas. They provide care and support to a wide range of people including, older people and people living with dementia and mental health needs.

The previous inspection of this service was carried out in September 2014. At this inspection we found that the registered person was in breach of six regulations, care and welfare of people who used the services, requirements relating to workers, (recruitment), supporting workers, and records. At this inspection the registered person had taken steps to meet the regulations with regard to requirements relating to workers and supporting workers. However, there were still breaches in the regulations with regard to care and welfare of people using the service and records. An ongoing action plan was in place to address the shortfalls.

There was 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 and associated Regulations about how the service is run. The registered manager had overall responsibility for this service; however there was a branch manager in post who dealt with the day to day running of the service.

Risks associated with people’s care had been identified, but there was not always sufficient guidance in place for staff to keep people safe.

People's medicines were not always handled and managed as safely as they could be. There was a lack of risk assessments in place to ensure that people received their medicine safely. Medicines were not listed or recorded appropriately so it was not clear what medicines people were taking. Some medicine records were not clear and were not accurate.

The service had not taken any new referrals since September 2014, so there had been no new assessments carried out. A new system of care planning was being introduced which was resulting in all of the people using the service receiving a visit from senior staff to carry out a new assessment which formed part of the new care plan. This process was scheduled to be completed in June 2015.

People were satisfied with the care and support they received, however records did not always confirm what action had been taken by office staff to ensure that people’s health care needs had been followed up, such as contacting district nurses or the GP. The care plans varied in detail. There was no guidance in the plans to show staff how to manage and reduce the risk of people developing pressure ulcers. Some care plans did not always show how people were receiving consistent personalised care in line with their choices and preferences. People were supported with their nutritional needs. People told us that they chose what they wanted to eat. Staff prepared meals and made sure people had enough to drink.

Records were stored safely but were not always accurate.

There was enough staff employed to give people the care and support that they needed, however there were times during annual leave or sickness when additional staff were required to cover the service. At these times administration staff from the office covered these calls to make sure people received their care. There was an ongoing recruitment drive to address the issue of office staff having to cover calls to people. Staff had received training in how to keep people safe and demonstrated a good understanding of what constituted abuse and how to report any concerns. Accidents and incidents were reported and action taken to reduce the risk of further occurrences.

New staff had induction training which included shadowing experienced staff, until they were competent to work on their own. Other staff who had worked at the service for over a year had received training to make sure they had the continued competencies, skills and knowledge to do their jobs effectively and safely. All the topics were covered in a one day refresher course. The registered manager and training manager had recognised that this was not enough time to cover the topics in the depth that staff needed. They were reviewing how they delivered the refresher training to make sure staff had more time and support to get up to date.

Staff had regular one to one meetings with a senior member of staff. At these meetings they had the opportunity to discuss any issues or concerns. Staff competencies were being ‘spot checked’ to make sure they were caring and supporting people safely.

Staff understood the current guidance to support people to make decisions and consent to care and support. Staff had received training on the Mental Capacity Act 2005. The Mental Capacity Act provides the legal framework to assess people’s capacity to make certain decisions, at a certain time.

People told us their regular carers were very kind and caring but other staff did not always have such a caring approach. They told us they knew their daily routines and were always polite and respectful. People we visited were relaxed with the staff and chatted to them about their care. They told us that the staff upheld their privacy and treated them with dignity at all times. Relatives told us that the staff encouraged their relatives to be as independent as possible whilst respecting their choices and wishes.

There was a complaints procedure in place. People told us they knew how to complain and when they had raised issues the staff acted on their concerns and resolved the matter promptly. Complaints were logged and responded to explaining what action had been taken to address the issues raised.

The registered persons were open and transparent with people, health care professionals and staff on the shortfalls of the service and on their action plan to improve the service. People were receiving telephone calls from senior staff to gather their views on the service and regular meetings were being held with health care professionals and staff to discuss the improvements required. Staff understood the visions and values of the service and felt things had improved now there was a new management structure in place.

There were systems in place to monitor the safety and quality of the service and actions plans had been developed and implemented to improve the service

We found a number of breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

Two adult social care inspectors, together with an Expert by Experience carried out this inspection.

We spoke with the registered manager, the new manager for the branch, three relationship managers, seven staff, the local safeguarding team and three local health care professionals.

We reviewed care plans and other records relating to the management of the service. We later telephoned fifteen people using the service and four relatives to gain their feedback about the service provided.

The service had expanded substantially since the previous inspection which had an impact on the quality of care being provided. Prior to the inspection we found that the service had identified areas of improvement and as a result had implemented an action plan which included the restructuring of the management team and staff. This will be closely monitored by the Commission to make sure the improvements are made.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what people using the service and others told us and the records we looked at.

Is the service safe?

The service did not have effective systems in place to make sure people were safe.

Staff recruitment policies and procedures were not being followed by the service to ensure safety checks of staff were in place before they were employed.

There was not enough staff to provide the service to people. Calls to people were missed and they told us that some staff were not staying for the allocated time. Different staff were visiting people so there was no consistency of care.

Some risks assessments did not contain sufficient guidance to ensure staff took a consistent approach and people remained safe. For example, when people needed support with their mobility the risk assessments did not detail how to do this safely and take into account people's medical conditions.

Accidents/incidents that happened in people's homes were recorded, but these were not analysed so that the service could learn from them, so they were less likely to happen again.

There were shortfalls in the recording and management of people's medicines.

Is the service effective?

The service was not effective. Staff had not received specialised and updated training. Staff were not receiving a yearly appraisal to identify their training needs and professional development.

One person had not received a detailed assessment and two people did not have a care plan in place. Care plans varied in detail to show how people's needs were being fully met. There were shortfalls in the plans to show how people's skin was being kept as healthy as possible. People's medical condition such as diabetes was not cross referenced to their dietary needs in their care plan to make sure they were receiving appropriate support to maintain a healthy diet.

People had access to a variety of health care professionals to support them with their health care needs. This was not effective as staff relied on the daily reporting instead of updating the care plans with the required information.

In some cases, records were not being completed appropriately.

The care plans did not show how people were being supported to make decisions. There was no system in place to assess people's capacity to make decisions that were made in their best interests.

Is the service caring?

Some staff were able to demonstrate that they knew the people they cared for well. They told us about people's preferences and choices and how to care for them in line with their needs.

People told us the staff were kind and caring. They said: 'The staff meet my needs very well'. 'They (the staff) are wonderful'. 'The staff are good and very nice'. 'If you need them to stay longer they will'. 'The ones I got at the moment are very good'. 'Mostly they seem ok'. One relative said, 'The care staff seem very good'.

Is the service responsive?

The service was not always responsive to people's needs.

There were mixed views from people using the service about the reliability of the service. Some people told us that they had missed calls and some staff did not always stay the full duration of the call. Other people said that on the whole the staff spent the allocated time of the call with them and usually arrived on time.

We could not track information from staff when they reported people's health care needs to the office as computer records were not available to confirm appropriate action had been taken.

Some people did not have a care plan to give staff the guidance to respond to their needs and in some cases care plans had not been reviewed and updated.

People and staff told us that communication with the office was not always effective. They said the office did not respond to their telephone calls or ring them back in a timely way. This also applied to the out of hour's service.

The quality assurance system in place only included feedback from people using the service. Relatives, staff and health care professionals did not have the opportunity to feedback about the services being provided.

Is the service well-led?

There was a new management structure in place as the service had identified shortfalls in the management of the service. At the time of the inspection there was a new manager and four new relationship managers. Relationship managers were senior staff responsible for assessing and reviewing people's care plans.

There was a lack of quality monitoring in the service to make sure people were receiving the care they needed. The audits to make sure the quality of service was being provided effective had not been carried out since March 2014 this was before the service expanded. Therefore, there was limited information to evidence that the appropriate checks had been made to make sure people were receiving the care they needed.

Staff received supervision although this was not in line with timescales within the services policy.

The service was first registered with the Care Quality Commission in March 2013. This was the first inspection of this small service since registration. At the time of our inspection 32 people were receiving help with personal care. We visited the office and spoke with the registered manager, the office staff and a care worker. We later spoke to six people who used the service, three relatives and four staff by telephone.

People told us that their privacy and dignity was respected and their independence was encouraged. People said they were happy with the care and support they received. One person told us "It's very efficient, the paperwork is clear and we're quite satisfied at the moment'. Another person said, 'It's been absolutely brilliant'. People knew about their care plans and had discussed their care and support with staff. People felt safe using the service and when staff visited their homes. People told us they thought that the service recruited the right calibre of staff. One person said, 'Most of them are all right'. Another person said, 'They are fantastic'. People said they had been asked for their views and feedback on the service provided. People told us they felt confident any concerns would be addressed.

Archived: Nightingale Homecare and Community Support Services Ltd

All Inspections

29 and 30 July 2015

During a routine inspection

26 and 27 February 2015

During a routine inspection

30 September and 1 October 2014

During a routine inspection

30 July 2013

During a routine inspection