Archived: Apex Prime Care - Alton

The service was last inspected in October 2016 when it was rated as good in all areas. Following this inspection in November 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.

Following the inspection the provider submitted an application to de-register this location and the management of the regulated activity for people who continued to receive care was transferred to another of their locations.

There was inadequate leadership and governance of the service. The service had seen frequent changes in management and there was a lack of a registered manager which had resulted in inadequate oversight of the service, lack of support for staff and poor quality of care. 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.

There were insufficient numbers of suitable staff to keep people safe and to meet their needs. People reported they had experienced late and missed calls and inconsistency in staffing. Staff had worked excessive hours to provide people’s care but the sudden departures of care staff at the end of October and November 2018 had precipitated a staffing crisis. On the morning of the inspection the service had to arrange to hand back 25 people’s care packages to Commissioners, to ensure people’s safety. The provider had failed to ensure full pre-employment checks had been completed for all staff and that staff had the skills required for their role.

People’s medicines were not managed safely. The guidance and record keeping in relation to medicines management meant that the provider could not demonstrate staff provided safe care in this area.

Risks to people had not always been identified, assessed or addressed within their care plans for people’s safety. There were not fully effective systems to protect people from the potential risk of financial abuse.

The provider did not have an electronic system in place to monitor when and if people received their care. The lack of an electronic call monitoring system meant we could not identify how many care calls had been missed. There had been a failure to identify and report missed calls to the local authority under safeguarding procedures as acts of neglect. The provider could not demonstrate people had always been sufficiently supported to ensure they ate and drank sufficient for their needs.

Staff had not all had the opportunity to update their training to ensure it remained current. One staff member was still rostered to provide people’s care although some of their training had expired in 2015. Staff had not all received supervision at all this year, which put people at risk of receiving ineffective or unsafe care.

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; the policies and systems in the service did not support this practice.

People did not consistently receive person centred care that fully reflected their needs and preferences. People’s care had not always been regularly reviewed and their care plans updated accordingly. People’s needs for accessible information had not always been identified. There was a lack of written information for staff to refer to about who was receiving end of life care.

There had been a lack of management oversight to monitor, assess and mitigate potential risks to people and staff from the provision of the regulated activity. Issues with the standard of care plans and staff recruitment had been identified at the start of 2018, but there had been a lack of effective action to address them for people. There had been a failure to effectively record, investigate and monitor people’s complaints or to identify trends.

People’s care needs had been assessed prior to the provision of their care and the provider had obtained commissioner’s assessments of people’s care needs. However, the provider was not able to consistently demonstrate people’s care and treatment had been delivered in line with legislation and current guidance to achieve effective outcomes for people.

There was mixed feedback from people and their families about how caring the staff were, some said staff were kind whilst others felt they were treated as a job rather than a person. People’s records did not consistently demonstrate what decisions they had been involved in by staff about their care. People’s privacy and dignity had been upheld.

There was not an open culture within the service. There was a culture of staff working excessive hours and staff had failed to alert senior management of the extent of the issues at the service, feeling they should cope themselves. There had a been a failure to alert external services with regards to the issues related to staffing to enable them to act to ensure people’s safety.

Processes were in place to seek people’s views on the service they received and staff’s views on the service. Staff were happy working for the provider.

The risks to people from acquiring an infection were safely managed. There were examples of how staff had contacted healthcare services for people.

Apex Care Alton provides domiciliary care support to 90 people in the community living in their own homes. The service also provides a range of other support outside the remit of inspection.

The service had a registered manager as required to manage its day to day operation. 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 relatives felt the staff were caring and kind. They told us staff supported their dignity and privacy effectively and involved them in making decisions about their day-to-day care. People were encouraged to do what they could for themselves.

People were involved in reviews of their care needs. Staff asked people’s consent before providing support. Office copies of care files were not in a consistent, orderly format.

Staff had been trained and knew how to respond to signs of possible abuse and how to report it. They felt the registered manager would respond appropriately to any concerns raised.

A robust recruitment process helped ensure staff had the skills and approach to care for vulnerable people. Staff received an appropriate induction and their competency was assessed. A programme of ongoing training was provided. Staff care practice was monitored through spot checks, carried out by management to observe their work.

Staff received ongoing support through supervision meetings. A programme of annual appraisal was beginning. Team meetings were infrequent but staff felt well supported through regular contact with the office and described management as supportive.

The service had a complaints procedure which people were told about and complaints were addressed appropriately by the registered manager. People’s views about the service had been sought by means of twice yearly surveys. The feedback was positive and where any issues had been raised they had been addressed.

The registered manager and provider monitored and reviewed the operation of the service and changes had been made where monitoring or feedback had identified issues.

We gathered information based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records. At the time of the inspection the service was providing care and support to 56 people in their own homes.

We spoke with five people who used the service. We sampled six people's care records. We spoke with three staff in addition to the registered manager and looked at three staff records. A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

This is a summary of what we found:

Is the service safe?

People told us they felt safe. One person told us: 'I have very good carers, staff are very good."

In general safeguarding procedures were robust and staff understood their role in safeguarding the people they supported.

People told us they felt their rights and dignity were respected. Care records included risk assessments and person centred care plans which promoted people's rights and dignity and reflected their choices and preferences.

We observed the service had a system in place to ensure that people's risk assessments and care plans were kept under regular review. The provider may wish to know we found reviews of the care plans of five people had not been completed in line with the provider's timescales. This was an area of improvement identified by the service and the manager told us there was action underway to establish systematic review procedures. The manager also informed us the service was recruiting further senior care staff who, in addition to the manager and care coordinator, would undertake reviews.

Systems were in place to make sure that managers and staff learnt from events such as accidents/incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The provider took people's care needs and preferences into account when making decisions about the numbers, qualifications, skills and experience required when allocating staff. This helped to ensure that people's needs were met.

Recruitment practice was safe and thorough. No staff had been subject to disciplinary action. New staff received a comprehensive induction prior to working alone with people who used the service and were regularly supervised.

The provider had an on-call out of hours service to ensure continuity of the service as part of its business contingency plan.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Care plans provided detailed information on how people wished to be supported. People's daily care record sheets included the date and what help and support was offered to the person.

People had a copy of their care plan and terms of agreement in their own homes. The people we spoke with all said they had a copy of their care plan.

Care staff told us they had regular supervisions. This ensured they were competent to deliver effective care to people who used the service.

Records of staff training demonstrated care staff had regular and appropriate training to enable them to meet the care needs of people using the service.

Is the service caring?

Feedback from people was positive, for example, one person told us: 'It's a good service, all very nice and caring.'

When speaking with staff it was clear that they genuinely cared for the people they supported and they said they were well supported by the manager.

People using the service, their relatives, friends and other professionals involved with the service were invited to complete a six monthly questionnaire to comment on the service. Where shortfalls or concerns were raised these were taken on board and dealt with.

Care records showed us the provider liaised with other professionals involved in a person's care and assisted people in obtaining services for example, carer breaks.

Is the service responsive?

People were supported to express their views and be actively involved in making decisions about their care, treatment and support. One person told us: 'The carers are very accommodating and flexible,' and further told us how they were enabled to go out.

The provider had arrangements in place to monitor complaints, accidents and incidents. This meant that learning from mistakes, incidents and complaints investigations ensured improvements with the service delivery was maintained.

Care records showed us the service worked well with other agencies and services to make sure people received care in a consistent way.

Is the service well-led?

The service had quality assurance systems in place. Records showed us that identified concerns and opportunities to change things for the better were addressed promptly. As a result the quality of the service was continuously improving. For example, the provider had identified a need to recruit additional staff to support their system of regular care plan reviews.

Staff told us they were clear about their roles and responsibilities and the need for following a person's care plan carefully and consistently. Staff had a good understanding of enabling people's choice and preference. Staff also told us they informed the manager if they identified concerns for example, if someone declined care.

Staff told us about the need for accurate reporting and record keeping and this was demonstrated in the daily records we sampled.

Staff said they contacted their supervisor and/or manager if they needed to raise any questions relating to the delivery and implementation of best practice. Staff had one to one supervisions regularly including spot assessments whereby senior staff 'shadowed' them during care delivery. This meant staff felt supported and were well-led.

The staff we spoke with all said they were provided with adequate training and had opportunities for extra training which was relevant to their roles for example the provider supported them to undertake national vocational training in care. This enabled them to perform their roles and to be accountable for their actions.

The manager showed us how the provider's head office monitored events which affected the compliance of the service, for example, staff training.