Comments received from people we spoke with were positive such as “very good service, very happy with the nurses” “couldn’t fault any of them, they are so kind and gentle, observant and supportive” and " efficient and on the ball " were made.

We looked at survey forms received by the service and comments such as “They have given me better quality of life “ “we couldn’t manage without the staff” "Everybody is great and helpful" " It is good because nurses check her" " very satisfied" and "keep doing what you are doing" were recorded.

We did not get direct comments from people who use the service but information from the latest survey sent out had good comments from patients such as "the information pack answers all of my questions” “ I understood everything in it “ and it is nice to be able to understand everything for a change”.

Comments from the survey forms sent to patients said “ the staff are very helpful,” “ everyone is very nice and understanding ," “ they are always polite and helpful whenever I phone,” “staff are very friendly and chatty,” “ they are helpful and I couldn’t do without them” “Friendly happy people.”

Staff spoken with said they are supported and encouraged to attend training and meetings to aid their continued professional development .

Staff spoken with said “ I love my job” “ it is a great place to work” “ We get a lot of support , it is a good company to work for”.

There were two organisations registered with the Care Quality Commission under one parent organisation at the same address. Calea UK and the parent organisation Fresenius Kabi were registered as Cestrian Court. In practice this meant there was one board of directors and one senior management team shared across both organisations. The provider did not hold separate information for each organisation and therefore the information provided for the inspection covered both Calea UK and Fresenius Kabi. This included training statistics, policies and procedures, human resources information and governance and risk processes. Where the information is pertinent to Calea UK only this has been specified in the report.

We found the following issues that the service provider needs to improve:

• There were systems in place for the reporting and investigation of safety incidents that were not fully understood by staff. The identification and recording of incidents was not clear as these were documented along with complaints.
• There was a lack of understanding and implementation of the duty of candour.
• The policies and procedures for safeguarding children were not robust.
• The majority of permanent staff and 42% of bank nurses had completed safeguarding training for children, however; this was to level two only and not the required level three.
• Prescription records for all patients were not always fully completed.
• Patient records were completed both on paper and electronically. We observed and the provider’s own audits had found that not all records were completed fully.
• Mandatory training rates were poor for bank staff at 54% completed.
• There was a lack of assessment and clarity of actions required for responding to patient risks.
• There was no audit programme in place.
• Policies and procedures were not always referenced and several key policies had been revised or come into effect immediately before the inspection.
• The clinical outcomes for patients were not measured.
• Not all staff had received an annual appraisal and there was no current formal supervision in place at the time of inspection.
• Not all staff competencies were consistently completed; therefore, we were not assured that staff had all the required skills.
• The six weekly field visits to assess staff competence were overdue for most staff.
• Patients’ mental capacity was not formally documented and not all staff were aware of their responsibilities towards Mental Capacity Act and Deprivation of Liberty safeguards.
• Patients did not have individualised care plans relating to their clinical, social or emotional needs.
• There was a lack of robust governance processes.
• There were gaps in the controls for identified risks and the system for escalation of risks and forums for discussion were not clearly documented.
• The information obtained in order to appoint directors was not adequate to meet the fit and proper persons’ regulation.
• If staff raised concerns they did not receive feedback.
• A staff survey showed some dissatisfaction with the communication within the organisation and nearly a third of staff did not feel valued by the organisation.

However we found the following areas of good practice:

• There was appropriate equipment to provide care and treatment for patients in their home.
• We observed staff following good hygiene practises when delivering care and treatment.
• The majority of permanent staff had completed mandatory training.
• There were vacancies across the service, however bank staff were utilised to make staffing levels sufficient.
• Patients had access to a 24 hour helpline for support and guidance.
• Staff had access to information including protocols and care pathways.
• We observed that verbal consent was obtained prior to any care or treatment.
• Services were delivered by caring, committed and compassionate staff that treated people with dignity and respect.
• Patients were involved in decisions about their care and treatment and told us they were given adequate information before, during and after treatment.
• Staff provided emotional support to patients and recognised the importance of involving families or carers in their care.
• Staff assisted patients with a flexible service to ensure treatment was provided to include life events such as social outings and holidays.
• New patients were provided with a comprehensive welcome pack. This included a step by step guide of what to expect, frequently asked questions and useful contact details including the advice line.
• Patients had access to the helpline if they wished to raise a complaint.
• Staff of all levels were complimentary about their immediate line managers and the senior management team.
• We were told there was an open culture and staff were able to raise concerns freely.
• Procedures were in place to protect staff that were lone working.
• The results of an annual patient survey showed a high level of satisfaction.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements to help the service to improve, even though a regulation had not been breached. We also issued the provider with four requirement notices that affected Calea. Details are at the end of the report.