About the service:

• Focus Care Link Ltd – Waltham Forest Branch is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community.

• At the time of the inspection 108 people at the time of the inspection.

People’s experience of using this service:

• People told us they felt safe with the carers but they were not happy with staff punctuality and communication from the main office when staff were late or missed a call.

• People’s risk assessments were not always robust in how to mitigate against identified risks. Instructions for staff were not clear where they were to support someone with moving and handling and equipment checks had not been followed up.

• Some assessments for people contained contradictory information about identified risks of choking. This put people at risk of unsafe care and the service did not meet the requirement of good in this area.

• Medicines were managed safely. People told us they received them on time and the recording of medicines given had improved. Where there were gaps in the medication administration records (MAR), people’s daily logs explained what had happened.

• People were supported by staff who had been recruited safely and who had been trained to support them.

• Staff showed awareness of the Mental Capacity Act 2005 and the need to support people with choice. However, the correct power of attorney details were not provided where relatives were making decisions on behalf of people who lacked capacity.

• People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

• Care staff were kind and compassionate and respected people’s privacy and dignity.

• Care plan personalisation had improved in that people told us staff asked them what they wanted. However, personal details had not been recorded in the care plans we viewed. The registered manager provided updated care plans with more personalisation following the inspection.

• Care was regularly reviewed by the provider and people confirmed this. People were given the opportunity to say whether their care package met their needs.

• Complaints were acknowledged and acted on and the service had received compliments from people who were happy with the care.

• The registered manager did not have oversight over the quality assurance processes used at the service. We could not access audits we were advised had been completed on care files. The quality assurance processes had not identified the issues we found regarding poor risk assessments, incorrect information in care plans such as people’s incorrect dates of birth, incorrect information about peoples background and health conditions and the presence of blank documents.

• People and staff were asked to provide feedback on the service and this was acted on. The provider showed they learned from accidents and incidents and held weekly meetings with office staff to discuss ways to learn and prevent them happening in the future.

Rating at last inspection:

• Rated Requires Improvement in September 2018. This is the third consecutive time the service has been rated as Requires Improvement.

Why we inspected:

• This was a planned inspection to see if the service had met the requirements of their improvement plan. The service had made improvements, but they were not consistent.

Enforcement:

• We identified a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in relation to good governance.

We made one recommendation about consent.

• 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 continue to monitor the service and ask for an action plan asking how they will immediately begin to improve.

We last inspected this service in September 2017 where it was rated ‘requires improvement’ overall, with an inadequate rating in ‘well led.’ This was because we found three breaches of our regulations. These breaches were in relation to risk assessments not being detailed or robust and people's medicine records were not fully completed and were not always accurate. People who used the service and their relatives told us they were unhappy with the service, particularly in relation to the unreliability of care workers and missed calls. An insufficient number of staff were deployed and staff were not receiving regular supervision. There was a complaints procedure in place however complaints were not analysed in order for repeat complaints to be avoided and audits and quality checks were not taking place. Management systems were failing to prevent staffing issues and monitor consistency in care.

At this inspection, we found that although some improvements had been made, there were still issues around risk assessments, medicines, staff punctuality and staff supervision. We found continuing breaches of regulations relating to safe care and treatment and staff supervision and asked the provider to submit an action plan to tell us how they were going to make the necessary improvements. We also asked the provider to send us specific documents on a monthly basis about people’s care to show us what improvements they had made since the inspection was completed.

The service is registered to provide personal care to people in their own homes. At the time of our inspection the service was providing care to 88 people. There was a registered manager at the service at the time of our inspection. 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.

Risk assessments were not robust and lacked detail. People’s medicines were not managed safely and medicine records were not up to date and contained gaps whereby it was unclear as to whether medicines for some people had been administered or not.

People who used the service and their relatives gave mixed feedback on the punctuality of care workers, and showed that people were not always happy with the care provided by the service.

Care workers were not receiving regular or consistent supervision to support them in their role and to address any training or development needs.

Management lacked oversight of the issues raised during the inspection but have been proactive in sending CQC updates on improvements they are going to make with supporting documentation.

People were protected from infection control and care workers had access to protective equipment such as aprons and disposable gloves.

Accidents and incidents were recorded and care workers told us they knew what to do in an emergency situation.

People were supported to have a balanced diet in line with their preferences and the service worked in conjunction with other organisations and teams to ensure people were receiving the care they needed. This included making referrals to health care professionals.

People who used the service told us they were treated in a caring way by their care workers and that they felt respected.

Care plans contained personalised information about people but we have made a recommendation that the provider seek best practice guidance to expand on the level of detail contained in care plans. We have also made a recommendation in relation to recording end of life preferences within care plans and pre-assessments.

The inspection took place on the 27 September 2017and was announced. This was the first inspection of the service since it was registered with the Care Quality Commission in February 2016. The service is registered to provide care to people in their own homes.

There was a registered manager at the service at the time of our inspection. 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.

The service was not consistently safe. Risk assessments were not detailed or robust and did not explore ways to mitigate risks that had been highlighted. In addition, people’s medicine records were not fully completed and records were not always accurate.

People who used the service and their relatives told us they were unhappy with the service, particularly in relation to the unreliability of care workers and consistently late and missed calls. People and their relatives told us about occasions where care workers had failed to attend and the consequences of this on their care and the rest of their family.

An insufficient number of staff were deployed and a number of staff had recently resigned from the service as a result of issues relating to pay and management. A group of staff had gone on 'strike' as a result of these issues and there were currently eight care workers employed to support 35 people.

Staff were not receiving regular supervision. Supervision that had taken place had not been recorded. In addition, staff appraisals had not taken place meaning that management were not monitoring the needs of staff.

There was a complaints procedure in place however complaints were not analysed in order for repeat complaints to be avoided. We have made a recommendation about the management of complaints.

Regular audits and quality checks were not taking place. Management systems were failing to prevent staffing issues and monitor consistency in care.

There was an on call system for care workers and people to call out-of-hours and records were kept of all calls received and actions taken.

Staff were knowledgeable about safeguarding adults and whistleblowing. The service had up to date policies and procedures in place regarding safeguarding adults and whistleblowing for staff.

The service had robust staff recruitment procedures in place.

Newly recruited staff took part in an induction and shadowing programme. There were certificates confirming that staff had passed their introductory training modules.

Care plans contained information about people’s medical needs and involvement with health professionals.

People who used the service and their relatives told us that although care workers were unreliable, when they did arrive they were caring.

Care plans were personalised and contained person centred information about people’s needs and backgrounds.

We found the provider was in breach of three regulations relating to safe care and treatment, good governance and staffing. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.