inspection report regulation of care act 2013 domiciliary ...€¦ · regulation of care act 2013...

Department of Health and Social Care

Rheynn Slaynt as Kiarail y Theay

Inspection Report

Regulation of Care Act 2013

Domiciliary Care

Home Instead Senior Care

Announced

17/10/17 9.30-14.30

18/10/17 9.00-12.00 23/10/17 9.30-12.20

Registration and Inspection Ground Floor, St George’s Court, Hill Street, Douglas, Isle of Man, IM1 1EF

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Contents

Completing and returning your report

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Provider’s action plan

Add details of your actions to complete the requirements/recommendations (if applicable)

Provider’s comments/response

Confirm you have read and agree/disagree the contents of the report by clicking on the appropriate box

State any factual inaccuracies found, add comments (if applicable) Sign (type name when returning electronically) and date

Return your report to [email protected] within 4 weeks

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This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection.

Part 1: Service information

Part 2: Descriptors of performance against Standards

Part 3: Inspection Information

Part 4: Inspection Outcomes and Evidence and Requirements

When making decisions the Registration and Inspection Unit have regard as to how well the service meets the Domiciliary Care and Child Care Agencies Standards (July 2013). Providers of services are required, as part of their conditions of registration, to fully comply with the minimum standards.

This report identifies strengths and areas of good practice as well as areas where, in order to meet the minimum standards, improvement is required. It also summarises the findings of an inspection of the service and any requirements and recommendations made. It will form the

Provider’s Action Plan

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mailto:[email protected]

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basis for decisions by the Registration and Inspection Unit regarding registration, any variation of registration conditions and any enforcement action.

Standard 3 – Contract

Standard 9 - Safeguarding

Standard 11 – Records kept in the home

Standard 12 – Recruitment and selection of staff

Standard 13 - Development and Training

Standard 14 - Qualifications Standard 20 - Quality assurance

In addition the following areas will be considered in each inspection:

Standard 19.4 Complaints

Part 5: Provider’s comments/response

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Part 1 - Service Information

Name of Service Wise care Ltd. Trading as Home Instead Senior Care

Tel No: (01624) 822545

Care Service Number ROCA/P/0192A

Provider Registration Number ROCA/P/0192

Address

8 Malew Street Castletown Isle of Man IM9 1AB

Conditions of Registration None

Registered Company Name Wise care Ltd. Trading as Home Instead Senior Care

Email Address: [email protected]

Name of Responsible Person Peter Heselwood – in process of being approved

Name of Registered Manager Martina Counsell

Manager’s Registration number ROCA/M/0173

Date of latest registration certificate 11/04/17

Date of latest manager certificate 11/04/17

Date of any additional regulatory action in the last inspection year (ie improvement measures or additional monitoring). None

Date of previous inspection 13/10/16

Number of individuals using the service at the time of the inspection 17 (seventeen)

Person in charge at the time of the inspection Peter Heselwood (17/10/17); Martina Counsell (18/10/17)

Name of Inspector(s) Egle Leadley

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Part 2 - Descriptors of Performance against Standards

Inspection reports will describe how a service has performed in each of the standards inspected. Compliance statements by inspectors will follow the framework as set out below.

Compliant Arrangements for compliance were demonstrated during the inspection. There are appropriate systems in place for regular monitoring, review and any necessary revisions to be undertaken. In most situations this will result in an area of good practice being identified and comment being made.

Recommendations based on best practice, relevant research or recognised sources may be made by the inspector. They promote current good practice and when adopted by the registered person will serve to enhance quality and service delivery.

Substantially compliant Arrangements for compliance were demonstrated during the inspection yet some criteria were not yet in place. In most situations this will result in a requirement being made.

Partially compliant Compliance could not be demonstrated by the date of the inspection. Appropriate systems for regular monitoring, review and revision were not yet in place. However, the service could demonstrate acknowledgement of this and a convincing plan for full compliance. In most situations this will result in requirements being made.

Non-compliant Compliance could not be demonstrated by the date of the inspection. This will result in a requirement being made.

Not assessed

Assessment could not be carried out during the inspection due to certain factors not being available.

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Part 3 - Inspection information

The purpose of this inspection is to check:

Is the care safe?

Is the care effective?

Is the care compassionate?

Is the service well led?

No Standard Requirements/recommendations from previous inspection

Met/not met

1 2.1 The manager needs to ensure that needs assessment is undertaken for every service user prior to the provision of domiciliary care service.

Not met

2 7.6 Care plans need to be updated and any agreed changes recorded and auctioned following the reviews.

Met

3 7.7 Care plans need to be signed by the service user or their representative.

Not met

4 Regulation 10 All notifiable events must be reported to the Registration and Inspection unit in line with Regulation 10 of the Regulation of Care (Care Service) Regulations 2013

Met

5 26.2, 26.4 & 26.5

The complaints policy and procedure needs to be amended to include all information identified in the standard.

Not met

6 17.4 All staff are confirmed in post only following completion of all satisfactory checks listed in the standard.

Partly met

7 19.2 The manager needs to ensure that a structured induction process is completed by all new staff members.

Met

8 24.1 The manager needs to ensure that all staff members are added to the system used for rota. To ensure that the records kept are accurate.

Met

9 4.3 To review the service agreements held by all clients as contact details need to be updated.

Met

10 21.2 to conduct and record all supervisions with staff and save them on the staff members file.

Not met

11 21.5 To record annual appraisal and to keep records on the staff members file.

Met

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Feedback from relevant parties

The inspector had an opportunity to visit three Home Instead Senior Care clients. All of whom were very complimentary about the staff and care they receive. All service users had Client files at their homes, which contained all required information. Some of the comments made during the visits were:

“Polite and respectful staff. Competent and know what they do”; “Does super job for me, never let me down”; “All staff have been introduced by seniors”; “Carers very good, no complaints”.

The questionnaires were also left for staff to fill in. Three questionnaires were returned. Staff who responded, demonstrated their knowledge of safeguarding and complaints policies and procedures. All respondents noted that they have received written contracts and were complimentary of the service induction process.

Part 4 Inspection Outcomes and Evidence and Requirements

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)

Standard 3 – Contract

OUTCOME

Each service user must have a written individual service contract for the provision of care with the agency.

Our decision:

Compliant

Reasons for our decision The inspector had an opportunity to examine seven randomly selected service user files kept in the office. All files contained service agreements that were signed and dated. The contract set out the some of the main terms and conditions and referred the reader to the statement of purpose which was incorporated to the service agreement. The service users who were visited by the inspector had copies of signed service agreement.

Requirements and recommendations None


Not applicable

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Standard 9 - Safeguarding

OUTCOME

Service users are protected from abuse, exploitation, neglect and self-harm.

Our decision:

Substantially compliant

Reasons for our decision

The service had safeguarding and whistleblowing policies in place. The inter agency adult protection policy 2016-2018 was also available for all staff. Safeguarding training was a part of the induction training. The training matrix showed that all staff completed this training. However the timescale for refresher training was not identified and a few members of staff completed the training more than three years ago. The manager must ensure that the refresher training is undertaken a minimum of every three years. There were no safeguarding issues recorded since the last inspection. However the systems were in place to record it. Feedback received from staff confirmed that they were fully aware of the safeguarding policy and procedure.

Requirements and recommendations

Standard 9.5 The manager must ensure that all staff members undertake refresher adult protection training at least every three years. Timescale: Immediately


New owners took over in June 2017 and have reviewed all processes. We have set up a new training matrix in order to ensure and monitor all training updates on an annual basis not just every 3 years, as 90% of staff have worked less than 12 months for us this is straight forward to implement, any longer serving staff have now been through a refresher course regardless of length of service being less than 3 years


Standard 11 – Records kept in the home

OUTCOME

The health, rights and best interests of service users are safeguarded by maintaining a record of key events and activities undertaken in the home in relation to the provision of support and care.

Our decision:

Compliant


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The inspector had an opportunity to examine three service user files kept at their homes. The files were well organised and contained up to date information. The written records seen were found to be legible, dated and signed by the carers as well as service users when appropriate. The manager explained that the logs were transferred to the office for safekeeping approximately every 6 weeks. The written logs are then audited by the management. The manager explained that all service users consented to have the records kept in their homes. Number of signed consent forms was seen by the inspector.

Requirements and recommendations None


Not applicable


Standard 12 – Recruitment and selection of staff

OUTCOME

The well-being, health and security of service users is protected by the agency’s policies and procedures on recruitment and selection of staff.

Our decision:


Reasons for our decision The service had a recruitment and selection policy in place. The policy was last reviewed in 2015 and the next review date was not identified. The inspector had an opportunity to examine nine randomly selected staff files. All nine files contained completed application forms, which included a declaration of health and evidence of Disclosure and Baring service checks. However some templates used to record DBS checks were not fully complete. Each file contained a minimum of 3 references, the majority of the files contained four or more references. Six files contained recruitment decision sheets, which contained an interview summary. Evidence of driving license checks was also available in the files. All files contained number of various training certificates. All but one file contained evidence of formal induction training, as well as a number of shadow/observations records. One file, which did not contain any induction evidence, belonged to the person who had been recently employed and was in the process of completing the induction. Three files seen contained signed terms and conditions of employment. The feedback from staff confirmed that they had been provided with a written contract. The induction workbooks were examined by the inspector. The induction consisted of three modules, which were in line with Common induction Standards as well as Standards of the Care certificate. All carers have been provided with the CareGiver manual which included code of conduct. The policy in regards to disciplinary procedures was in place. No disciplinary incidents were recorded since the last inspection.

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Requirements and recommendations Standard 12.2 &12.3 The manager must ensure that each staff file contain evidence of all required checks and documentation. Timescale: Immediately Standard 18.2 The manager must ensure that policy and procedure documents are regularly reviewed and dated to indicate the date of the review and when the next review is due. Timescale: February 2018


After new owners took over We have implemented a 12 week induction review meaning all staff have regular meetings and reviews, reviews are weekly for the first 6 weeks then fortnightly for the remaining 6 weeks then monthly ongoing, this is fluid as some staff may require weekly meetings for a longer period. These meetings and reviews are documented and assist in mentoring and development of all staff going forward.


Standard 13 – Development and Training

OUTCOME

Service users know that staff are appropriately trained to meet their personal care needs, except for employment agencies solely introducing workers.

Our decision:

Partially compliant


The service had a training matrix in place. However it did not identify the frequency of refresher training. The manager must ensure that all staff members receive all mandatory training and the refresher sessions within identified timescales. Specialist training (e.g. diabetes) required must also be provided. The manager must ensure that the record of all training attended by staff is kept. Formal induction process was in place and written evidence of it was available for the inspection. The induction process consisted of three days of classroom training as well as shadowing and observations of the practice. The records of which was also kept. The manager explained that six and twelve weekly reviews were held with new employees; however these meetings were not recorded. The manager must ensure that the performance reviews during the probationary period are evidenced. The inspector had an opportunity to examine

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supervision and appraisal evidence. The majority of the staff, whose files the inspector examined were new in the posts, therefore they did not have annual appraisals in place. However staff who had worked for the service longer than a year did have annual appraisals in place. There were some inconsistencies in the supervision evidence. A number of staff files did not contain evidence of the required number of supervisions.


Standard 13.1 The manager must ensure that there is a staff development and training programme in place, which includes all mandatory training and refresher training. Timescale: January 2017 Standard 13.3 The manager must ensure that the performance reviews during the probationary period are evidenced. Timescale: Immediately Standard 13.4 & 15.1 (previously 21.2)

The manager must ensure that all staff receive a formal supervision at least 3 monthly and a written record must be kept on the content and outcome of each meeting. 02/11/15 Timescale: Immediately Partly met Carried over 13/10/2016 Timescale: immediately Not Met Carried over Timescale: Immediately


All staff now have formalised development and mentoring meetings, training and development plans are covered within these meetings to ensure all information is captured and Staff can develop their own training requirements in addition to all statutory requirements. The 12 week Probabtion, induction and on going training is fluid depending on the ability and confidence of the staff member, this can be extended if required

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Standard 14 Qualifications

OUTCOME

The personal care of service users is provided by qualified and competent staff.

Our decision:



The manager was studying towards the QCF level 5 diploma. She presented as knowledgeable, eager to learn further and improve the service. The majority of the staff team was newly employed. The staff members had all mandatory training; however majority did not have QCF level 2/3 qualifications. The manager must ensure that at least 50% of staff are qualified to QCF level 2/3 or equivalent. The manager must also ensure that the person deputising for the manager in her absence is qualified to a QCF level 3 diploma or equivalent.


Standard 14.2 The manager must ensure that 50% of all staff are QCF level 2/3 or equivalent. Timescale: November 2018

Standard 16.4 The manager must ensure that the person deputising for the manager in her absence is qualified to a QCF level 3 diploma or equivalent. Timescale: December 2018


We have set up QCF level 3 training with a training provider on the Island beginning in January for 60% of our team.


Standard 20 – Quality assurance

OUTCOME

The service is run in the best interests of its service users.

Our decision:


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A quality assurance system was in place. The manager visited clients regularly and at least annually. Visit logs as well as staff timesheets were audited by the senior staff. The evidence of the audits was available for the inspector to see. The system to record and monitor any complaints and compliments was in place. The manager carried out and recorded unannounced spot checks to monitor the standard of the careers work. The feedback from staff confirmed that they were aware of the standard of service they were required to provide. An annual report was not available for the inspection. The manager must ensure that an annual report is completed and is made available to all. An annual report must list the success and introduce a written development and improvement plan based on the outcomes of the quality assessment information.


Standard 20.4 & 20.6 The manager must ensure that an annual plan is in place. An annual report must list the success and introduce a written development and improvement plan based on the outcomes of the quality assessment information.

Timescale: April 2018

Provider’s action plan A new business development plan is in place and all successes, complaints, issues or process

changes are documented. All improvement plans and actions will be reviewed, implemented and documented within the annual report.

ANY OTHER AREAS EXAMINED


Standard 19.4 Complaints

Criteria

The registered person must ensure that when complaints are accepted they are recorded. The complainant receives a written acknowledgement, and following an investigation, a written outcome. The acknowledgement will be received by the complainant within the seven days of making the complaint. The outcome will be received by the complainant within twenty eight days. Where the outcome is delayed the complainant will be advised in writing of the delay.

Our decision



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A complaints policy and procedure was in place, it was dated 10/08/15. The policy has not been reviewed since the last inspection and therefore still did not contain all information required. The manager must ensure that the policy is reviewed to cover all areas listed in the standard. The complaints folder was seen by the inspector. No complaints were recorded since the last visit. The record of compliments was also seen by the inspector. One compliment was recorded since the last inspection.


Standard 19.1 & (previously 26.2,26.4,26.5) The manager must ensure that the policy is reviewed to cover all areas listed in the standard. 13/10/2016 Timescale: immediately Not Met Carried over Timescale: Immediately


New owners took over in June 2017 and a full review of all policies took place, we now have a rigourous complaints procedure in place and these procedures are reviewed and audited on a monthly basis.


Other Areas Identified during this inspection


Care plans The inspector had an opportunity to examine six client files. All files contained up to date care plans and regular reviews were evidenced. The review meeting minutes evidenced involvement of the client and were appropriate their family/representative. However the care plans seen were not signed by the client and/or their representative. Assessments The manager explained that the initial care needs assessment was carried out prior to the provision of domiciliary care. All six files seen contained up to date care plans, which included assessment of needs. However a number of files seen by the inspector did not contain evidence of the initial care needs assessment, therefore it was difficult to determine if the initial care needs assessments were carried out prior to the service commencing. Feedback received from the service users confirmed that initial assessments were taking place and were carried out by the manager.

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Standard 6.5 (previously 7.7) The manager must ensure that the care plans are signed by the service users and/or their representatives. 13/10/2016 Timescale: Immediately Not Met Carried over Timescale: Immediately Standard 2.1 The manager must ensure that a care needs assessment is undertaken, prior to the provision of the domiciliary service and evidence of this assessment is available for the inspection. 13/10/2016 Timescale: Immediately Not Met Carried over Timescale: Immediately


Documentation has been changed by the new owners and all client care plans are now signed by clients. All services are reviewed on a weekly or monthly basis depending on requirements, care plans are designed to be fluid and reflect the changes needs of the clients.

Please complete the provider action plan sections beneath each requirements and recommendation section providing details of action taken (or to be taken) with timescale for each. The inspector would like to thank the management, staff and service users for their co-operation with this inspection. If you would like to discuss any of the issues mentioned in this report please do not hesitate to contact the Registration and Inspection Unit.

Inspector:

Egle Leadley Date: 10/11/17

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To: Registration and Inspection Ground Floor, St George’s Court, Hill Street, Douglas, Isle of Man, IM1

1EF From: Home Instead Senior Care

I / we have read the inspection report for the unannounced inspection carried out on 17th, 18th, 23rd of November 2017 at the establishment known as Home Instead Senior Care, and confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s). ☒

I/we agree to comply with the requirements/recommendations within the timescales as stated in this report. ☒

Please return the whole report which includes the completed action sections to the Registration and Inspection Unit within 4 weeks from receiving the report. Failure to do so will result in your report going on line without your comments.

Or

I/we am/are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) ☐

Click here to enter text.

Signed

Responsible Person Peter Heselwood

Date 01/12/17

Signed

Registered Manager Peter Heselwood

Date 01/12/17

Action plan/provider’s response noted and approved by Inspector:

Date: 09/01/17 Signature/initials EL

Part 5 Provider’s comments/response

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