Ison Nursing Agency and Care Services Ltd

Ison Nursing Agency and Care Services Ltd is a domiciliary care agency. It provides personal care to adults living in their own homes, with a range of disabilities. At the time of the inspection it was providing care to 79 people.

People’s experience of the service

People and their relatives told us staff were extremely competent in their caring role and were kind. People had consistent care staff the majority of the time, so they fully understood people’s needs and how they liked care provided. Relatives told us they had full confidence in the care provided and the management team were responsive if any issues arose.

At the last inspection we found a breach of the regulations in relation to the management of the service. We found that whilst the management team and care staff knew people’s needs well and provided a personalised service to people, this was not always reflected in the care records and risk assessments. At this inspection we found there were significant improvements and the service was no longer in breach of the regulations. The management team had risk assessments in place, implemented regular audits and people and their relatives told us the management team were regularly in contact with them.

People were safeguarded against the risks of abuse and harm by the systems and by the staff, who received training in safeguarding adults. Safe recruitment practices took place, so staff were considered appropriate to work with vulnerable people.

Medicines were safely managed and people were supported with nutrition and hydration as needed.

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.

We saw that the service worked in partnership with other health and social care professionals. People were supported to access external health professionals to help promote good health and wellbeing. Health and social care professionals told us the service worked effectively with them and communicated well.

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 the service was requires improvement (published 20 January 2020). There was a breach of regulation in relation to the management of the service. 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 inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

Ison Nursing Agency and Care Services Ltd is a domiciliary care agency. It provides personal care to adults living in their own homes, with a range of disabilities. At the time of the service it was providing care to 44 people.

People’s experience of the service

Most people were happy with the service and told us staff were kind to them, and understood their needs. Most family carers were also happy with the service, and told us the management team dealt with issues they raised.

We found a breach of the regulations in relation to the management of the service. We found that whilst the management team and care staff knew people’s needs well and provided a personalised service to people, this was not always reflected in the care records and risk assessments.

Quality assurance processes were not always documented adequately so the management team could not always evidence they were providing a good service despite most people being happy with the care provided, and the service being praised by health professionals. The management team were not able to monitor timekeeping by care staff at the time of the inspection, and some people told us they were not always notified when staff were running late. The service had identified this issue and were in the process of addressing it at the time of the inspection.

People were safeguarded against the risks of abuse and harm by the systems and by the staff. There were enough staff to meet people’s needs and provide responsive care. Safe recruitment practices took place so staff were considered appropriate to work with vulnerable people.

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.

People were supported to access external health professionals to help promote good health and wellbeing. Health and social care professionals told us the service worked effectively with them and communicated well.

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 the service was good (published 28 June 2017).

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.

At our last inspection in October 2016, we found two breaches of regulations. These related to the lack of an effective system for identifying and responding to complaints by service users and other persons, and the governance of the service.

After the last inspection in October 2016 we imposed a condition on the provider's registration requiring them to send us monthly audit reports about complaints, medicines audits and checks of the electronic work allocation system. The provider submitted these monthly. We undertook this comprehensive inspection to check on the progress made by the provider, and to consider whether restrictions placed on the service in August 2016 to prevent them from providing personal care to anyone new to the agency without our written permission could be removed.

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 2008 and associated Regulations about how the service is run.

People and their relatives told us they were happy with the care provided by the service. People told us staff were caring and kind and were skilled to do the job. People’s relatives said staff did not rush people, and treated them respectfully and kindly. The same staff were supplied to people wherever possible. This helped positive relationships to develop where staff knew people’s needs and preferences, and people received familiar staff.

Staff were supported in their role through an induction, training and supervision. Staff told us office staff were available to offer advice if they had any concerns, and understood what to do if they were concerned about a person. However despite undertaking training, a number of staff were not able to tell us the different types of abuse, nor understood clearly how to ‘whistleblow’. This is the action to take if a staff member is concerned that issues raised in an organisation are not being acted upon. The registered manager undertook to hold another workshop in the next month with staff to refresh their knowledge and understanding of these issues.

Staff recruitment records showed appropriate checks and references were taken up before staff started to work with vulnerable people.

Risk assessments were detailed and up to date and covered the risk areas identified in people’s care plans. They provided clear advice to staff in managing these risks.

At the last inspection there were occasions when electronic visit records placed the same staff member in two people’s homes at the same time, which was not possible. At this inspection we found the electronic system had been updated and now prevented this happening. The provider used the system to check visits had taken place and tasks had been completed.

At this inspection we saw governance of the service had improved. The new electronic system was now being used by the provider to prompt for supervision, training and reviews. The registered manager ensured audits were taken of medicine administration records; checks of quality of the service were undertaken by office staff and we could see a recruitment audit had been undertaken in the last six months. The provider now had an effective system to deal with complaints. Many of these systems were newly established and would take some time to embed fully to become routine management tasks.

The agency is registered to provide homecare services to anybody in the community. However, as a result of the service entering Special Measures following the January 2016 inspection, and remaining there since the May 2016 inspection, we imposed a condition on the provider’s registration to prevent them from providing personal care to anyone new to the agency without our written permission.

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 2008 and associated Regulations about how the service is run.

At the time of this inspection the agency was providing a care service to 26 people in their own homes. Whilst the provider is registered for the agency to provide nursing care to people in their own homes, the registered manager told us this was not being provided to anyone at the time of our inspection.

There was good feedback from most relatives of people using the service. They confirmed that they would recommend the service to friends and family. There was particular praise for the registered manager’s responsive approach to people’s care needs.

However, we found insufficient improvement in the management of the service. A number of recent staff rotas showed that staff visit scheduling tools at times allocated individual staff members to visit two people’s homes at the same time which is not possible in practice.

There were occasions when electronic visit records placed the same staff member in two people’s homes at the same time. We found that these records could not be trusted to ensure that staff were visiting people on time and for the full length of time.

Whilst there was some live monitoring of electronic visit records, the provider’s systems were not effective at identifying and addressing risks connected to the new electronic care delivery records not being made or being written late.

People’s concerns and complaints were still not always promptly and effectively investigated so as to minimise the risk of reoccurrence where appropriate. This was despite complaints audits helping to identify and address more concerns and complaints. In particular, one relative had to keep raising the level of complaint before matters were addressed. Complainants were not routinely told of how to raise concerns with independent authorities if dissatisfied with how the agency dealt with their complaint.

Records of supporting people with medicines continued to be inaccurate, and there were insufficient checks of these records by senior staff so as to identify medicines risks. We could not be assured that people were supported to receive their medicines as prescribed.

A new electronic care planning system was now in place based on detailed risk assessments, particularly for the control of infection and the management of pressure care. Care plans were accessible to staff through work-supplied phones, and so they could be easily kept up-to-date. We recognised that a lot of work had gone into setting up this system so as to better enable staff to meet people’s current needs and respect their preferences.

People’s relatives said staff did not rush people, and treated them respectfully and kindly. The same staff were supplied to people wherever possible. This helped positive relationships to develop where staff knew people’s needs and preferences, and people received familiar staff.

People received support with nutritional and health needs, and there was evidence of good liaison with community healthcare professionals. People were supported to be involved in decisions about their care, and consent to care was appropriately sought.

Recruitment procedures made satisfactory checks of prospective new staff members’ character and identity. Staff received sufficient training and support to enable them to have the skills needed to provide effective care to people. Unannounced checks of staff at people’s homes were effective at identifying care delivery risks.

As a result of this inspection, enough progress had been made to address our concerns about people’s safety and welfare, and so the agency was removed from Special Measures. However, there were two breaches of regulations, which are listed at the back of the full version of the report.

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

The agency is registered to provide homecare services to anybody in the community. 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 2008 and associated Regulations about how the service is run. The registered manager was also the nominated individual for the registered provider.

At the time of this inspection the agency was providing a care service to 38 people in their own homes. Whilst the agency is registered to provide nursing care to people in their own homes, the registered manager told us this was only occurring for one person.

The provider’s action plan in response to our last inspection told us they would have addressed all the regulatory breaches by the time of this inspection. However, at the start of this inspection, the registered manager gave us an updated action plan that clarified that they had not addressed some breaches as quickly as anticipated and so there was ongoing work to complete matters.

We found that the provider was making improvements to the service, and was thereby improving on service quality that people received. However, they remained in breach in the following four areas:

People did not always receive safe care and treatment. This was because people were not safely supported with taking medicines, and records of this support were not properly kept. Additionally, actions were not taken to reduce foreseeable risks in relation to people’s specific needs, including for nutrition and pressure care.

Staff support did not always enable effective care delivery. This was because new staff did not receive adequate induction before providing care, staff were not routinely supervised, training was not effectively provided for nutrition and pressure care awareness, and staff did not always receive realistic visit schedules.

Complaints were not always handled and investigated effectively. Some complaints were not responded to, and investigation processes did not always address matters effectively.

Governance systems were not yet effective at reducing risks to care delivery. Governance systems were being developed that helped identify service risks to people’s welfare, but actions to address identified risks were not yet effective, including for ensuring that people received the full length of their care visits and that staff were not late. Records about people’s care and the management of the service were not consistently accurate and complete, despite improvements to care delivery records and their oversight.

Further surveys had been sent to people since our last inspection for their views on service quality. There was ongoing work to analyse these, to identify what worked well and what needed improving. Staff had also now been sent similar surveys.

Care assessment and planning did now incorporate the views of people using the service and their representatives where appropriate. New care plans were better at guiding staff on addressing people’s needs and preferences, although the registered manager acknowledged that this reviewing and updating process needed completing for some people.

The provider had updated systems to acquire consent to care delivery. These had been used properly so as to gain valid consent or establish that best interests processes were needed.

The service continued to provide a consistent set of care staff to most people, which helped to build positive caring relationships. Most feedback we received indicated that the service supplied caring staff.

Staff were now supplied to provide care to people only after appropriate checks of their character were completed.

Spot-checks of staff in people’s homes were now being regularly undertaken. They were being used to check on a range of service quality markers including people’s views of the service.

There were overall four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

We are taking enforcement action against the registered provider and the registered manager. We will report further on this when it is completed.

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 2008 and associated Regulations about how the service is run. The registered manager was also the nominated individual for the registered provider.

The agency is registered to provide homecare services to anybody in the community. At the time of this inspection the agency was providing a care service to approximately 50 people in their own homes. Whilst the agency is registered to provider nursing care to people in their own homes, the registered manager told us this was not occurring in practice.

We found a number of breaches of legal requirements at this inspection. This put people using the service at unnecessary risk of receiving inappropriate or unsafe care.

We found that staff were supplied to provide care to people before appropriate checks of their character were completed and before sufficient training had taken place, which compromised the safety and welfare of people using the service. References were not routinely obtained from previous care employers. Where recruitment checks identified risks, the service did not always respond appropriately, which further compromised the safety of people using the service.

The provider was not taking all reasonably practical steps to ensure that people received their planned care visits. Care delivery records were not consistently accurate and complete, and there were no effective systems for checking these so as to establish whether a gap in care delivery meant a missed visit had occurred. The registered manager acknowledged that there were staff vacancies which they were actively trying to address.

Risk was not adequately assessed in people’s homes, including in respect of medicines and the environment. There was insufficient action to ensure that moving and handling support was provided to people safely, despite two accidents involving moving and handling support during the previous year.

People did not consistently receive the full length of their care visits, which did not indicate a caring approach to people’s needs and preferences. However, the service did provide a consistent set of care staff to most people, which helped to build positive caring relationships.

The service did not have an effective complaints system that listened to, documented and learnt from people’s concerns and complaints.

Care assessment and planning did not routinely incorporate the views of people using the service and their representatives. Whilst care plans were developed from needs assessments, plans did not respond to some identified needs and did not reflect people’s preferences. The care-planning approach to people’s end-of-life care needs and preferences did not support people to have a comfortable, dignified and pain-free death.

Care plans were not routinely reviewed and were not always reviewed when people’s needs changed. This did not support people to receive care that fully addressed their needs and reflected their preferences.

Whilst the provider had set up systems to acquire consent to care delivery, the systems were not being used properly so as to gain valid consent or establish that best interests processes were needed.

Contracts agreed with privately-funded people and their representatives were not signed and did not stipulate costs. This did not promote an open and empowering culture.

Staff were not consistently supported for their care delivery roles as they did not have all training necessary for those roles.

There were ineffective systems for ensuring high quality care and good management. Spot-checks of staff in people’s homes were not undertaken for all staff and were not effective at checking and acting on a range of service quality markers. Surveys sent to people for their views on service quality were not analysed to identify what worked well and what needed improving. Accurate records were not consistently maintained, which compromised quality auditing processes. There was insufficient management oversight of care services to people and staff support for those roles.

There were overall eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. We are taking enforcement action against the registered provider and the registered manager. We will report further on this when it is completed.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.