Triangular Care Services Limited

Triangular Care Services Limited is a domiciliary care service providing the regulated activity personal care, which is help with tasks related to personal hygiene and eating, in people's own homes. At the time of our inspection 10 people were receiving personal care.

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

Systems to support the governance and performance management of the service continued to be ineffective. There was little evidence of learning, reflective practice and service improvement. The provider and registered manager had failed to identify improvements were needed. Audits had failed to identify poor record keeping, which included incomplete documentation. Records were not stored in an accessible and organised manner to enable effective oversight of the service.

There continued to be limited analysis of feedback provided by those using the service and their relatives, which included an analysis of questionnaires, concerns and complaints. Continued poor governance and oversight had impacted on the provider’s ability to identify shortfalls and in their ability to develop plans to improve the management of the service.

People’s needs were assessed. However, improvements were needed to ensure the assessment process was sufficiently recorded and assessment records completed in full. People’s capacity to make informed decisions was documented. However, records had not been completed in accordance with the Mental Capacity Act (MCA), which demonstrated a lack of staff’s understanding and knowledge of the MCA. We found no evidence this had impacted on people’s choices.

People’s care and support needs were detailed within multiple paper based documents, which made it difficult for staff to easily access information. This left people vulnerable to inconsistent care being delivered. People were aware of how to raise concerns. However, multiple paper based records and how they were stored made it difficult to determine if all concerns had been responded to.

People were supported by staff who had undergone a recruitment process. There were sufficient staff to meet people’s needs. People and their family members spoke positively of the reliability and good time keeping of the staff. Systems to record the management of people’s medicine had recently been transferred to an electronic monitoring system, which had improved the systems and practices of medicines management. Staff worked consistently within the provider’s policy and procedure for infection prevention and control.

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 and family members contributed to the assessment process. People's health care needs were documented, and staff liaised with family members regarding people's health and wellbeing where required. People were supported with their dietary needs. Staff had the required experience, knowledge and training to meet people's needs.

People and their relatives spoke of the kind and caring approach of staff. They told us their privacy and dignity was respected and their views were respected by staff. New staff were introduced to people and their family members before they started providing support and care.

People and family members were involved in the development and reviewing of their care needs. People were supported to take part in activities and engage in social events where support had been identified as part of their assessed package of care. People and their relatives were aware of how to raise concerns.

People and their relatives spoke positively of the management of the service, which included good communication between themselves, the registered manager and staff. Staff and an external professional were positive about the day to day management of the service, and of the commitment of the registered manager in the support of people and the staff team.

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 8 August 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve safe medicines management and quality monitoring of the service provided. At this inspection we found the provider remained in breach of regulation 17.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Enforcement

We have identified a continued breach in relation to the leadership and governance of the service.

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 work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Triangular Care Services Limited is a domiciliary care service providing personal care to older people in their own homes. At the time of inspection, the service was supporting 26 people.

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.

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

People felt they received a good service and the staff treated them extremely well. Staff were caring and kind and people felt safe in their care. However, we found a number of concerns that required improvement and had the potential to put people at risk of harm.

People’s medicines were not adequately recorded. We found medication administration records were inconsistently completed and did not reflect the medicines people received. People’s risk assessments were not sufficiently detailed and did not effectively consider how risks could be minimised. Safeguarding systems were in place, however not all staff understood how to report any concerns of abuse.

Improvements were required to ensure staff worked effectively with other agencies involved in people’s care needs, for example other healthcare services. Further improvements were required to ensure people received appropriate support with their dietary and nutritional needs.

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. However, the policies and systems in the service did not always support this practice.

Care plans did not contain sufficient guidance about how people’s care needs should be met. Care plans were not updated regularly, or when people’s needs had changed, and this left people vulnerable to inappropriate care being delivered to them.

People were asked basic information about their end of life wishes, however not all staff were aware of these wishes. This had the potential that people’s wishes would not be respected in urgent circumstances.

Significant improvements were required to how the service was monitored and audited. Audits were in place however, they failed to effectively identify and act on the required areas for improvements.

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 this service was Good (published 15 November 2016).

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Responsive and Well Led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to how medicines are managed and how the quality of the service is reviewed.

Please see the action we have told the provider to take at the end of this report.

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 inspection was announced and took place on 18. 19 and 21 October 2016.

The service had 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.

People felt safe and were protected from harm or abuse by staff that were aware of the principles of safeguarding and reporting procedures. Systems were in place to identify and manage risks within people’s homes and to empower them to be as independent as possible. Staffing levels were sufficient to meet people’s needs and keep them safe. Safe recruitment processes were in place. Safe arrangements were in place for the administration, recording and management of medicines.

Staff had received training and demonstrated an understanding of people’s individual needs and how to meet them appropriately. The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that people who used the service had capacity to make day-to-day decisions. However staff and the registered manager understood their responsibilities in line with the MCA requirements. Staff understood the importance of treating people with dignity and respect and people confirmed this.

People were provided with nutritional support if this was an assessed part of their package of care. Systems were in place to respond to people’s healthcare needs.

People were happy with the care they received from staff and felt they had forged meaningful relationships with them. They told us they were treated with kindness and compassion. Staff were respectful of the decisions people made.

People had their support needs assessed and reviewed on a regular basis, so that staff knew how to support them to maintain their independence. Care plans contained person centred information. Staff understood the importance of meeting people’s individual needs and provided the care and support they required. The service had systems to obtain people’s feedback and provide them with opportunities to raise concerns.

There was an open and positive culture at the service, with a clear set of values which people, staff and the management all worked towards. Quality control systems were in place to ensure care was delivered to a high standard and identify areas for development. Staff were keen to drive further improvement and to make the service the best that it could be.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Triangular Care Services Limited on our website at www.cqc.org.uk

During our previous inspection on 4 November 2016, we found that one of the regulations relating to care, welfare and records, was not being met.

Systems for medication administration were not effective in ensuring people received their medication safely and appropriately. Records did not always show what medication or dosage people were prescribed, and the administration of medication was not always recorded correctly. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

During that inspection we also found that the provider had failed to implement and operate sufficient quality assurance procedures, to maintain the quality of the care being delivered. There was a lack of effective audit and quality assurance processes, and policies and procedures were not available to all members of staff. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We asked the provider to submit an action plan to tell us how they would meet these regulations in the future, they stated that they would be meeting them by February 2016. During this inspection we returned to see if the service had made the improvements they stated in their action plan. We found that the provider was now meeting this regulation.

Triangular Care Services Limited is registered to provide personal care for adults in their own homes and when out in the local community. They currently provide support for older people with a range of needs, including people who may be living with dementia. On the day of our visit the service provided support for 47 people in their own homes.

Improvements had been made to the systems in place for medication management. Medication records were completed in full and cross referenced with people’s care plans. Checks of staff and completion of records had been introduced, to ensure medication was being given correctly.

There had also been improvements to the systems for quality assurance and managerial oversight at the service. New checks and audits had been implemented which were based upon the most up-to-date regulations, and forms and policies were available for staff members to use and refer to.

This inspection showed that the manager had taken steps to arrange appropriate training for staff. We saw evidence that staff had been generally rotered properly so that they could meet the needs of people who use the service.

This was a mixed positive inspection. The manager said that he had not received the previous inspection report so had not been able to act on the issues identified. He said that there had been a problem with the internet provider and a registered e-mail address had needed to be changed. However, we had not been formally notified of this change. The provider had therefore not been sent a copy of the last inspection report. This meant that some issues had not been fully followed up.

The essential standard we inspected with regard to providing comprehensive staff training had therefore not being met. The manager has provided us with information as to how relevant training will be organised.

We will undertake another follow-up inspection to check that this is in place.

A person told us that staff were good at their jobs. She said; 'staff are there to help if I need them'.

We spoke with the relatives of three people. They all told us that care was good, staff seemed to be well trained and they knew how to provide proper care.

One relative said; 'I have never had any concerns. Staff are marvellous. Nothing is too much for them '.

This was a mixed inspection. People we spoke with told us they were satisfied, or mainly satisfied, with the care they received. All their relatives we spoke with said that care was good. However, the essential standards we inspected with regard to comprehensive staff training and support, and dealing with complaints were not met. We are concerned with the history of non compliance with essential standards. If non complain continues we will seriously consider enforcement action.

There were some suggestions made; for better communication from head office to inform people that staff were running late, for head office to be more immediately contactable so that decisions regarding care could be made as soon as possible and for head office to always support staff. And to ensure that staff rotas are drawn up so that they are not expected to deal with a number of clients at the same times. The manager stated he would follow up these issues.