We carried out an announced comprehensive inspection on 12th June 2018. Following this inspection, we received a number of additional concerns which prompted further regulatory action. On the 10th and 11th July 2018 we carried out a further unannounced inspection so that we could fully assess the potential of ongoing risk to people.121 Care and Mobility Limited is a domiciliary care agency, it provides personal care to people living in their own homes. The service provides support visits to people in Whitstable, Herne Bay, Faversham and surrounding areas who are mainly older people, and some younger adults. At the time of the inspection they were supporting 292 people. Not everyone using 121 Care and Mobility Limited receives 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 the inspections in June and July 2018, the registered manager’s registration was being processed by CQC. The registration is now completed and there is a registered manager at the service. 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.
At our previous inspection on 21 and 22 February 2017, we rated the service as Requires Improvement having found breaches of Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk because the service was not assessing health related risks and ensuring measures to keep people safe were in place. Audit systems were not utilised effectively to identify and respond to shortfalls identified by people and staff. We asked the provider to take action to meet the regulations. We received an action plan on 11 May 2017 which stated that the provider would be meeting the regulations by 01 July 2017.
At this inspection, we found that the previous breaches had not been met and that there were further breaches of Regulations relating to: not ensuring that people were kept safe, failing to ensure care plans were reviewed regularly to reflect people’s needs; not consistently protecting people’s dignity; not meeting the requirements of the Mental Capacity Act; not protecting people from risks; not ensuring that systems and processes for safeguarding people had been put in place; and not responding to safeguarding risk in a timely manner, not meeting nutritional and hydration needs effectively; not ensuring governance systems monitor and improve the quality of the service; not ensuring sufficient competent staff were delivering the care and not ensuring an accurate CQC rating was displayed at all times.
People had not been kept safe from risk of harm. Risks had not been adequately managed and risk assessments had not been updated in a timely manner to ensure that risks had been correctly identified and actions put in place to lessen the risks.
Environmental risks had not been correctly assessed so that necessary infection control measures could be introduced to provide a safe working environment in people’s homes, for example during food preparation.
The provider had not carried out adequate individual risk assessments for people joining the service and there was insufficient detail to individualised care-related risk assessments to support people’s specific health and care needs, their mental health needs, medicines management, and equipment requirements.
Medicines had not been managed safely and people had not always received their prescribed dosage on time. Medicine administration was not correctly recorded and medication errors had occurred.
People’s changing needs had not been correctly recorded. We found gaps in care plans and essential risk assessments for example, to mitigate the risk of choking or falling, had not been completed with key follow up actions and learning by the provider, so that people could be kept safe from dangerous situations that might cause significant harm to them.
The provider did not have adequate processes in place to monitor the delivery of the service and staff communication systems were not effective in ensuring that all of the staff team were consistently updated to any changes.
People’s needs and choices had not been assessed effectively. Care plans were in place but there was a lack of essential details which left room for error and confusion and some staff were unaware of changes that had been introduced to plans. We have made a recommendation about this in our report.
The provider followed effective recruitment procedures to check that potential staff employed by the service were of good character and had the skills and experience required. All staff received core induction training at start of their employment covering key subjects to enable them to carry out their duties with refresher training provided at intervals. Sufficient numbers of staff were employed to meet people’s needs and provide a flexible service.
People were not consistently supported with meal planning and preparation, and eating and drinking as required. Choking risks had not been adequately assessed and staff had not sufficiently ensured that people had been supported to maintain healthy eating where guidelines had been put in place for health purposes.
People were supported to attend routine and follow up appointments if required. However, we reviewed care plans that showed a lack of detail around people’s health needs, especially where clear professional guidelines from trained professionals would ensure that people could be supported to reduce and manage their health risks more effectively.
Consent had not consistently been sought and the principles of the Mental Capacity Act 2005 (MCA) had not been complied with.
People told us they felt supported by the staff team. People liked staff and told us they were ‘really kind and thoughtful’. People told us they felt their choices and homes were respected by the staff team. People’s independence was supported by staff at home and staff protected people’s dignity by explaining what they were doing during personal care.
Information was kept safe in locked cabinets at the provider’s offices with copies in people’s homes. Staff understood the need for confidentiality; but on occasion, information sharing had lacked dignity and respect.
Peoples care plans had not been sufficiently developed with their input. There was a lack of evidence of personalisation so that people’s choices and wishes could truly reflect their needs holistically.
People said that they knew they could contact the provider at any time, and they felt confident about raising any concerns or other issues. Complaints had been logged and we found evidence of follow up by the registered manager. However, complaints information was not available in assessable format for people with communication difficulties. We have made a recommendation about this in our report.
People’s care plans contained no evidence of end of life care planning even though a significant number of people were older with complex health needs. We have a made a recommendation about this in our report.
The organisations vision and culture had not been reflected through a clear and credible delivery strategy for delivering high quality care and support. Staff did not appear to work collaboratively and this was having a negative impact on the quality of the service offered to people.
Quality monitoring and audit systems were ineffective and there was a lack of urgency about addressing some of the high and complex risks. The service has not demonstrated a commitment to driving improvement and breaches from the last inspection had not been addressed.
We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.
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.