The Office

The Office (AKA Personal Assistant Care Agency Ltd PACA) is a domiciliary care service registered to provide personal care 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 four people were using the service. Of these, two were receiving 24-hour personal care in their own homes and had a range of care needs including learning and physical disabilities.

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

We (CQC) 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.

Based on our review of the safe, effective and well-led key questions, the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

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’s rights were respected, and staff supported them to be as independent as possible.

Everyone told us the care and support provided by staff was kind, compassionate and personalised. One person described regular care staff as, "The best carers they had ever had," and "Just brilliant." Recruitment was ongoing to ensure there were always enough staff to cover leave and absence.

Staff understood how to respond to concerns about abuse and harm. Staff had been trained to support people with their medicines in a safe way and they understood the importance of good hygiene and the prevention and control of infection.

Staff had the right training and skills to carry out their roles and meet people’s needs. They made sure people had enough to eat and drink, and if anyone became unwell, staff knew how to access health care services to support people’s health and wellbeing.

There was positive feedback about the registered manager, who people described as approachable and helpful. The registered manager had worked hard and invested in a new electronic records system, to make a number of improvements across the service since the last inspection.

However, we found some of these improvements were only recent, and more time was needed to implement them fully. This included the completion of a new monitoring audit that would allow the registered manager to check the quality of the service in all the areas that we (CQC) look at when we inspect registered services.

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 21 April 2020) 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.

This service has been in Special Measures since April 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer in breach of regulations or rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

However, the service remains rated requires improvement. This is based on the findings at this inspection. We could not improve the overall rating on this occasion because to do so requires consistent good practice over time. We will check this again at our next planned comprehensive inspection. This means the services has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions: safe, effective and well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Office on our website at www.cqc.org.uk.

This was an ‘inspection using remote technology’. This means we did not visit the office location and instead used technology such as electronic file sharing to gather information, plus phone calls and emails to engage with people using the service as part of this performance review and assessment.

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.

Personal Assistant Care Agency (PACA) is a domiciliary care service registered to provide personal care to people living in their own homes. Not everyone using PACA receives 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 take into account any wider social care provided. At the time of our inspection three people were receiving 24-hour care in their own home.

The service didn’t consistently apply the principles and of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

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

People using the agency were not fully protected from abuse or from potential harm. While one person told us, they felt safe with the staff, not all staff had attended training in safeguarding of adults at risk. The perception of some staff was that people with learning disabilities were to be treated as children and imposed punitive measures for some behaviours. Where people were at risk of abuse from staff this was not reported by the staff who witnessed poor practice. The provider followed appropriate procedures when this practice was drawn to their attention. We raised a safeguarding alert to the lead authority.

Risks were not mitigated, and some individual risks were not assessed. Behaviour plans were not in place for people that placed themselves and others at risk of harm. Records showed there were people subject to punitive measures which staff confirmed during the inspection. Some staff lacked insight into people’s cognitive impairments and were intolerant of people’s behaviour.

Some people were not supported to have maximum choice and control of their lives and some staff did not support in the least restrictive way possible and in their best interests. Mental capacity assessments were not carried out to ensure the least restrictive option was taken. Court of Protection applications were not made for people subject to continuous supervision and for restrictions on their liberty.

For one person their relatives were taking decisions without having the appropriate legal authority to do so. Some decisions taken by the relatives were punitive, For example, restriction? Of attendance at day centres and finances. We made the safeguarding team and commissioner aware of our concerns. Where audio sensors or bed sides were used risks assessments or mental capacity assessments were not completed.

The staff were not always caring as they lacked insight into the needs of people with learning disabilities. People were seen as children and cared for in that way by some staff.

Care plans were not reflective of people’s needs. The person we spoke with told us they were not told about their care plans. For some people their rights were not respected. One person we spoke with told us the staff never knocked on their bedroom door before entering or closed the bathroom doors during supporting with care. Two staff said because the house was open plan and the person didn’t like the doors closed, they rarely asked for an invitation to enter the bedroom.

Medicine systems were not safe. Medicine administration records (MAR) were not accurate or up to date. Protocols for when required medicines were not devised. Medicines were removed from their original packaging into a separate unlabelled multi compartment systems which lacked directions.

Recruitment processes were not robust. Recruitment checks were not always conducted, and application forms did not meet the requirements of the legislation. There was little evidence on the assessment of risk where there was a lack of pre employment checks. This meant risk assessment did not demonstrate the decision on the employment of staff was robust.

The staff told us there was insufficient staff to cover sickness and annual leave.

Mandatory training set by the provider did not include the needs of people with learning disabilities. The staff had not always attended the training set by the provider.

People made some decisions about their meals.

People were supported on their healthcare appointments. Epilepsy profiles from specialists were not in place for one person. Clear guidance on the types of seizures with the staff’s actions was not provided.

The provider lacked an oversight of the service. Action plans were not detailed. During our feedback the provider told us there were more regular contact with staff. The provider has agreed to develop an action plan with timescales and to forward a copy to us

The staff said the provider didn’t always respond to their telephone calls.

For another person we saw good interactions between them and the staff. A relative praised the staff for their caring and kind approach towards their family member.

The provider had identified staff training needed to improve and had contacted training agencies to access online training packages. Consideration was being given to the introduction of electronic systems for staff to record medicines administered.

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 17 April 2019).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches at this inspection in relation to:

Poor safeguarding processes placed people at risk of harm.

While we found no evidence that people had been harmed however, systems were either not in place or robust enough to demonstrate safe care and treatment of people.

People’s mental capacity was not assessed. Relatives had taken decisions without the legal authority to make them. Applications were not made for Court of Protection where people’s liberty was restricted or under continuous supervision.

Staff recruitment was not robust. Staff did not attend training that developed their skills and they were not supported with their roles and responsibilities.

The provider lacked an oversight of the agency.

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.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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, 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.

Personal Assistance Care Agency Ltd. is a domiciliary care service registered to provide personal care to people living in their own homes. Not everyone using Personal Assistant Care Agency Ltd. receives 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 take into account any wider social care provided. At the time of our inspection 14 people were using the service.

People’s experience of using this service:

Quality assurance systems were not effective. The service manager was assessing and monitoring the quality of care delivered. An improvement plan was devised and was based on their assessment which included care planning. Although the improvement plan was recently introduced this had yet to be embedded into practice.

There were people receiving personal care who were at risk of potential harm. The daily notes showed people’s individual risks included mobility needs, people who experienced severe epilepsy and choking risks. However, risk assessments on how risks were to be mitigated were not available at the agency office.

The staff told us risk assessments were developed for some people. However, their comments indicated where risk assessments were in place they were not read by the staff and were in need of reviewing.

Risks assessments for the property were not in place. This meant the registered manager could not be certain that staff were working in a safe environment.

Customer details and comprehensive assessments were in place for some people. However, care plans were not developed from these assessments. There was no evidence that people’s care needs had been reviewed.

Records of daily visits documented by staff lacked their signatures and times of visits. There was little evidence on how staff had met people’s agreed outcomes.

People told us staff supported them with taking their medicines. The staff lacked an understanding on effectively recording the support they provided with medicines administration. For example, prompting and removing medicines from the packaging. This meant staff were not maintaining accurate records of medicines they had administered. Copies of medicine administration records were not available at the agency office for auditing. Comments from staff indicated that good practice guidance for medicines was not followed, NICE guidelines (National Institute for Health and Care Excellence).

Recruitment of staff was not well managed. Copies of application forms were not always fully completed. Applications forms did not always give the names of the most recent employer. There was no evidence that references had been sought for all staff.

Disclosure and Barring Services (DBS) checks had taken place for all staff. A DBS check allows employers to check whether the applicant has any convictions or whether they have been barred from working with vulnerable people. Where DBS checks were returned with convictions there was no evidence that the registered manager had assessed with the staff the learning from these episodes. This meant the registered manager had not gained reassurances that these incidents would not be repeated.

Recruitment was ongoing and a team leader had been appointed. The registered manager and the service manager told us the appointment of the team leader would assist with the monitoring of staff practice, undertaking care plan reviews and updating records.

There was support for staff through staff meetings. The most recent team meeting was well attended and all areas of the staff’s role and responsibilities were discussed.

People told us they felt safe while staff from the agency were present. The staff told us they had attended safeguarding of adults training. These staff knew they types of abuse and how to report any concern. There were three safeguarding referrals made before the inspection by CQC in response to concerns .

Although we received concerns that visits were missed, staff told us some visits were late but they were completed as required. People agreed with the staff comments. People told us they mostly had the same staff deliver personal care.

The staff told us the registered manager was approachable and supportive. People were confident the appointment of new managers would instigate improvements.

Rating at last inspection:

This service was rated good at the last inspection dated 22 February 2019.

Why we inspected:

This inspection was brought forward due to information of concern raised about staffing concerns and the impact this had on people.

Follow up:

The overall rating will remain Requires Improvement overall.

The provider will be required to tell us what action they will be taken to ensure compliance is met where breaches of regulations were found. We will monitor all intelligence we receive about the service which will inform when the next inspection should take place.

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

Personal Assistance Care Agency Ltd. is a domiciliary care service registered to provide personal care to people living in their own homes. Not everyone using Personal Assistant Care Agency Ltd. receives 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 take into account any wider social care provided. At the time of our inspection, 20 people were using the service.

A registered manager was 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.

Medicines were managed safely but some administration records required more detail, such as prescription guidance. People were protected from the risks associated with infection control.

Risk assessments were in place for people’s home environments. Not all personal risk assessments were in place although staff knew how to support people appropriately and safely.

There were sufficient numbers of suitable staff on duty to meet people’s needs and staff benefited from one to one supervision support from their manager.

Staff were knowledgeable about their responsibilities to report any concerns and knew how to identify abuse and what to do about it.

Although staff were knowledgeable about the Mental Capacity Act (2005), there were no recorded mental capacity assessments where there were doubts about people’s capacity.

Staff training was behind schedule and most required refreshers. New staff followed an induction process which was aligned to the Care Certificate.

People’s choices and preferences were detailed in their support plans. People and their relatives had been involved in developing and reviewing the plans. People were supported to attend activities, day services and maintain hobbies and interests.

The service worked collaboratively with health and social care professionals to develop appropriate support plans and make changes when required. Staff followed guidance given by specialists to support people using best practice methods.

Feedback received from people, their relatives, and visiting professionals was very positive about how caring the service was. Staff promoted people’s privacy and dignity and were respectful in their approach and methods.

The service was developing new ways of recording and documenting care plans, daily records and people’s care information. This was in the early stages of implementation. This meant that not all records were organised or up to date. However, a new service manager was being recruited. They would work alongside the registered manager and take over the day to day running of the service.