We carried out an announced comprehensive inspection of this service on 25 and 31 October 2017. 1st React Healthcare Domiciliary Care Agency is registered to provide personal care to people living in their own homes. The agency provides care to people living in Exmouth and the surrounding areas. When we visited, the service provided a personal care service for 42 people.

We previously inspected the service on 27 and 28 July 2016. At that inspection the service was rated requires improvement overall as the safe, effective, responsive and well led domains were rated requires improvement. The caring domain was rated as good. Three breaches of regulations were identified at the previous inspection related to medicines management, person centred care, and good governance. The service sent us an action plan to show how they would improve in these areas.

At this inspection, we found improvements in medicines management, person centred care, and in quality monitoring.

The service has a registered manager. 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.

Medicine systems had improved so people received their medicines safely and on time. All staff had regular competency assessments to check their medicines management skills and knowledge. People felt safe using the service and said it was reliable. Regular care staff visited them who they got to know and trust. Concerns were identified about staff rotas with overlaps in people's visit times which meant staff couldn't be on time for some visits. We have made a recommendation about improvements needed in this area.

Staff knew about the signs of abuse, how to report concerns and their responsibilities to protect people. The service had not notified the Care Quality Commission (CQC) about three concerns about suspected abuse, although these had been appropriately dealt with the local authority safeguarding team. A notification is information about important events which the service is required to send us by law. The registered manager and provider are now aware of their responsibilities and have since sent us retrospective notifications. Staff were aware of risks and people’s risk assessments identified steps staff needed to take to promote people’s safety and welfare. Recruitment processes ensured people were cared for by suitable staff.

Staff had the skills and training needed to carry out their role and undertook regular training relevant to needs of people they cared for. People confirmed staff sought their consent before providing any care. Where people lacked capacity, staff demonstrated a good understanding of the Mental Capacity Act (MCA) (2005) and how this applied to their practice.

Staff developed positive and caring relationships with people. Care staff were motivated, people mattered and staff spoke with kindness and compassion about the people they supported. People confirmed staff respected their privacy and treated them with dignity and respect.

People's care was individualised to their needs. Staff enabled people to remain as independent as possible. People's care plans had improved, were more personalised, detailed and comprehensive and described positive ways in which staff could support them. People knew how to raise any concerns or complaints and felt confident to do so and action was taken in response to make improvements.

The culture of the service was open; people, relatives, professionals and staff were positive about leadership at the agency. Care and office staff worked well together as a team. The provider and registered manager worked well together, promoted good standards of care and developed the staff team. The service had a range of quality monitoring systems

We carried out an announced comprehensive inspection of this service on 27 and 28 July 2016. The provider was given short notice because the location provides a domiciliary care service and we needed to make sure that someone would be in. Prior to the inspection we had received two concerns regarding infection control practices of care staff and people’s dignity not being maintained. As part of this inspection we looked into these concerns. We found staff had received infection control training and were supplied with gloves and aprons which people said they used. People confirmed their dignity was maintained.

1st React Healthcare Domiciliary Care Agency is a small domiciliary care agency registered to provide personal care to people living in their own homes. The agency provides care to people living in Exmouth and the surrounding areas. The service is managed from an office in Exmouth which is easily accessible for people, relatives and care staff. The length of time of visits was variable and depended upon the needs of the person. For example one person received a 15 minute visit to support them with medicine administration whilst others received visits of one hour. The agency also provided some sleep in cover to support people in their own homes. The frequency of visits ranged from one visit a week to four visits a day. At the time of inspection, the agency was providing personal care to approximately 43 people and employed 29 care staff.

There was not a registered manager in post at the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act and associated regulations about how the service is run. The provider has a condition on their registration to have a registered manager in post. They have submitted an application to CQC to have this condition removed. This was because the agency has only a single location and the provider managed the service herself. The provider was supported by an assistant manager and a deputy manager. Following the inspection the provider made us aware that they had withdrawn their application to remove the condition of having a registered manager in post. They confirmed an application was being submitted for a new registered manager .

People and their relatives felt safe, cared for and supported by care staff in their own homes. They were treated with kindness and respect. However some people were not happy as they did not have consistent care staff especially during holiday periods. Where there were missed visits the provider took action to try and prevent the risk of this happening again. They informed people of changes by telephone calls and schedules being issued .

Staff were recruited safely. They undertook an induction and received training and worked with experienced care staff doing shadow shifts. However once new care staff had completed their induction they were not monitored and assessed to ensure they were delivering good care until they had their six monthly supervision and annual appraisals. Following the inspection the provider made us aware that they had made changes to improve staff monitoring and competency observations.

At their supervisions and appraisals staff had the opportunity to discuss concerns and any further training needs. Staff felt supported in their work. Staff meetings took place and staff felt communication was good at the service.

People’s medicines were not managed in a safe and appropriate way. Improvements were required in how medicines were recorded to guide care staff to safely administer them. Care staff had not had their competence assessed to demonstrate they could administer medicines safely, which is good practice.

People had an assessment carried out when they started using the service. Care plans did not gi

The agency was inspected by the Care Quality Commission in January 2014. We found that improvements were required relating to care workers who had not received up to date supervision or appraisals. This meant that care workers did not have opportunity to discuss personal development or issues such as training and development on an individual or confidential basis.

Following the inspection the provider wrote to us and, in a detailed action plan, described the arrangements that would be put in to place to achieve compliance. We visited the agency and we found that the provider had made all the necessary improvements to become compliant within this area.

We (the Commission) carried out this review to check the service’s progress regarding non-compliance with aspects of the Health and Social Care Act 2008 found at our last inspection. These issues were discussed in our previous report about the service, which is dated August 2011.

We initially visited the service’s office unannounced on 26 January 2012, where the registered manager and a new manager provided us with information we requested. We returned for a second visit on 31 January 2012 by arrangement. We spoke with thirteen people who used the service or with their advocate, visiting two people in their homes and speaking with others by phone. This was just over a quarter of the total number of service users. Another person declined to speak with us. We also spoke with seven of the staff team, either in person or by phone, which was again about a quarter of the staff team. This contact took place over three days.

People indicated that they, or their relative if we spoke with advocates, received the care they wanted or needed, and they felt safe with staff. Punctuality of staff in the morning was an issue for some people, however. When we asked if staff discussed and agreed what support they wanted daily, all but one person confirmed that this happened. Two people commented that they had had to tell new staff what to do. Another person told us that new employees visiting them had worked with other staff initially, which we learnt was a relatively recent practice.

The care records we read were individualised, with individuals' preferences regarding their care being available to staff, for example. Occasionally these and other records were not updated in a timely way, creating a risk that people could receive unsafe or inappropriate care. We found quality assurance systems were not robust enough to address some risks to people or promote the quality of the service, and that the service had not taken action to safeguard people as much as possible.

Most people were positive about the staff who supported them, some staff being singled out for particular praise. Most people told us they had some ‘regular’ staff as well as seeing various other staff. Two people said they had thought about moving to other agencies but didn’t because they liked the staff. Another person told us they had been pleased when they used the service in the past so contacted them again, and continued to be happy with the service.

People we spoke with told us that they had discussed their care plan with senior staff, and that they received the support they needed or wanted. They felt that staff listened to them, and respected their decisions. They knew of the care records kept in their homes, although some said they chose not to read them. Care plans were not always sufficiently detailed to ensure consistent and appropriate support would be provided, however.

One person was impressed particularly by the care provided by young staff members to their elderly relative, including how they managed very personal problems such as incontinence. They said staff communicated in such a way as to cheer the person up and promote their dignity. Other people confirmed that they had been asked whether they had any preferences about the gender of staff that provided personal care. One person commented that not all staff called out to introduce themselves when they let themselves into the person's house, which would be polite.

The service had carried out a survey in the last year on dignity, involving people who used the service and staff. The majority of responses were positive. People we spoke with felt their privacy was respected, one describing this as ‘brilliant’.

Staff were said to handle individuals gently and in an unhurried way, regularly explaining what they were about to do and checking if the person was alright.

People felt staff were observant of their health, noticing if they were under the weather or had health problems. Some were also supported by the community nursing team and hospital services. These people felt that 1st React worked well with them and the other services, to ensure they received required care, were able to attend appointments and so on.

Some had equipment which staff used in meeting their needs. They confirmed it was serviced regularly, although such arrangements had not been included in their care plan. Two had noted that staff checked equipment before using it.

One person we spoke with confirmed none of their visits had been missed. Another said the service had put in a telephone at their home after a visit was missed, and one visit had been missed since this. A third person also reported one missed visit, whilst another person said a couple of visits had been missed in the last year.

There were various reasons for these missed visits, but communication was a theme. Communication had also been identified as an issue in recent surveys carried out by the service. One person told us it was easy enough to get hold of the office staff but they weren't so good at responding to questions. Another felt the office were good at following matters up reported to them. A third said that sometimes office staff weren't available because they were out on care visits. A professional we spoke with thought ‘communication could be better’ (as did some staff) as they sometimes had to ‘chase up’ a response.

During our visit to the office, we heard office staff contacting someone who used the service to tell them their carer was running late. One person we spoke with had no concerns about staff punctuality. One said staff were occasionally late but always let the person know. Another indicated that staff might arrive up to half-an-hour later than the expected time, though they were not concerned about this. Someone who said there was usually a good reason if staff were running late (which they said happened only occasionally) told us they wanted to be better informed of any lateness, because they had certain needs. People told us that if staff arrived late, they still stayed the agreed time.

We saw people had singled out various staff for praise on surveys carried out by the service. Someone commenting on the staff said “Very pleasant, kind, helpful, and they always say 'Can I do anything else for you?' ", which other people reflected.

One person told us they had known the carers that supported them for a long time, and others said they were supported by a core of staff familiar to them. Three people indicated that the service asked for feedback or checked if they were ‘getting on okay’ with any new staff; the service would remove new staff if the person thought they wouldn’t be able to get on with them.

People who chose to speak to us by phone (rather than us visiting them) confirmed that they had contact numbers for the service should they need to raise anything with them. Three indicated they felt able to complain, and had had a good or satisfactory response from the service when they did. We spoke with someone who had made a complaint. They had been kept informed of the service's subsequent actions, the problem having been addressed promptly.

On the day of our inspection, the agency was providing personal care to 31 people. People we spoke with told us they felt that care workers treated them with respect. Comments included “they treat me with kindness, always”.

People who used the service and their relatives told us they were very happy with the care they received. They said “the carers are marvellous”. When we spoke with care workers it was evident they knew people well.

People were properly safeguarded from abuse as care workers were clear on the procedures to follow if they had any concerns. The provider's had a safeguarding policy which contained the right procedure for care workers to follow when allegations of abuse were made.

Care workers had not received up to date supervision or appraisals. This meant that care workers did not have opportunity to discuss personal development or issues such as training and development on an indivividual or confidential basis

There were systems in place to monitor and improve the quality of the service provided. Everyone we spoke with told us there was nothing to complain about. We found records were kept in a way that protected people's safety and welfare.