This comprehensive inspection took place on 27 April 2017 and 2 May 2017 and was announced. The provider was given 48 hours’ notice of the inspection because the location provides a domiciliary care service and we needed to be sure someone would be in at the office.

Helping Hand Domiciliary Care Service is a domiciliary care agency based in Chorley in the County of Lancashire offering a range of personal care services in people's homes, including people living with dementia, learning and physical disabilities and people with palliative care needs. Services provided include, domestic support, waking and sleep in night services, 24 hour care and respite care. At the time of inspection the registered provider was supporting 49 people and employed 29 members of staff.

The service is operated by an individual who also manages the service on a day-to-day basis. There was no requirement by the Commission to have a registered manager in place.

A comprehensive inspection of the service took place in October 2015. At that inspection issues were raised following concerns over the management of medicines. Staff were not always correctly recording the administration of medicines to people.. Concern was also raised about the measures the service had in place to improve and build on the improvements that were seen at that inspection.

At this inspection on 27 April 2017 and 2 May 2017 it was noted that improvements had been made to ensure prescribed medicines were suitably managed and recorded and that the service had continue to improve and had implemented systems to ensure that quality of care was monitored. It was seen that this had led to improvement in the quality of the care plans and risk assessments and to the service generally.

People told us that when they required assistance with their medicines, staff were reliable and knowledgeable and we observed that staff were completing accurate records for administering medicines.

People were protected from the risk of abuse. We noted care plans and risk assessments were reviewed and updated when people’s health care needs changed or when new risks were identified. People who used the service told us their nutritional and health needs were met.

People spoke positively about the quality of service provided and spoke highly of the staff. People consistently told us improvements had been made within the service in the past 12 months. They said staff were reliable and turned up when expected most of the time. If they were running late, because of traffic or some other issue, the office contacted people to advise of a revised time for the call.

People who used the service told us they felt safe and secure. Staff had knowledge of safeguarding procedures and were aware of their responsibilities for reporting any concerns.

People’s healthcare needs were monitored. Care plans were developed and maintained for people who used the service. Care plans covered support needs and personal wishes. Plans were reviewed and updated at regular intervals and information was sought from appropriate professionals as and when required.

Staff had an understanding of the Mental Capacity Act 2005 (MCA) and the relevance to their work. We saw that mental capacity was routinely assessed and good practice guidelines were referred to when a person lacked capacity.

Training was provided for staff to enable them to carry out their tasks effectively. The service was working proactively to identify staff training needs. Staff praised the training on offer.

Suitable recruitment procedures meant staff were correctly checked before starting employment.

The provider had implemented a range of assurance systems to monitor quality and effectiveness of the service provided. We saw that audits were being carried out on a monthly basis by the management team and noted action had been taken when concerns were identified.

Systems were in place to seek feedback from all people who used the service as a means to deve

We looked at the information we had gathered under the standards we inspected. We used the information to answer the five questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This a summary of what we found:

Is the service safe?

Four of the five staff we spoke with demonstrated an awareness of safeguarding. All were able to identify signs of abuse and the appropriate procedure to follow if they suspected abuse had occurred. One staff member told us, “I would report any concerns no matter what to my line manager”.

We looked at the safeguarding file and saw evidence of the investigation taking place; however there was no outcome noted by the provider. We discussed this with the provider who confirmed they would contact the relevant authority to obtain a conclusion.

We looked at risk assessments in five care files. We noted inconsistencies in the documentation. For example one person’s file had no details recorded for risk assessments and two further records had basic information and not been reviewed since June 2012 and August 2013.

Is the service effective?

Staff we spoke with confirmed they had received regular training relevant to their role. The manager showed us a training matrix which identified topics covered by staff. Examples seen were, moving and handling, fire, infection control, medications and basic food hygiene. We saw evidence of certificates of training obtained in four of the five staff files that we looked at.

Of the five staff files we looked at only two had completed interview records, one record was incomplete, one was blank and the third was missing. Two of the staff files identified information that required further exploration by the manager. We spoke with the manager about this who told us discussions had taken place with the staff members involved however, there was no evidence of this being recorded.

Is the service caring?

We spoke with people who used the service and their family members about the care and support they received. Examples of some comments received were, “I am very happy with my care. The girls are very nice” and, “The carers [staff] are excellent, on the whole I have no qualms about the care at all”.

We noted there were care plans in place in the files we looked at however we saw inconsistencies in the documentation and signing. For example, one file contained a detailed care plan to show the person’s individual needs. Another care plan had been dated from June 2012 but it had not been signed.

Is the service responsive?

At our last inspection we identified the care plans were very task focused and were not personalised with measured outcomes. Four of the six care plans we reviewed continued with a task focused approach which meant there were no systems in place to ensure staff were aware of personalised individual needs for people who used the service. However two care plans were more detailed containing personalised information, these however still consisted of task focused documentation.

At our inspection we spoke with the provider about the staffing numbers for the service. We were told they were fully recruited and sickness or holidays were covered by their own staff team. Four of the five staff we spoke with told us they felt there was enough staff on duty to meet people who used the service’s needs.

We asked the manager to provide us evidence of how they monitored the quality of service provision. The manager told us, checks on care plans, medication sheets and staff logging in was regularly monitored. We saw a quality audit file in place that was a self-assessment document for audits on the service. We looked in this file however, this had not been completed. The manager told us they were planning to commence using this document the following week of our inspection.

We were shown copies of completed questionnaires that the manager told us had been returned recently to the office from people who used the service and their families. We saw evidence of feedback in them. An example of a comment was, ‘You provide me with a very good service which I am more than happy with’, ‘Excellent helpful friendly service; this is our third agency and is the best, I would recommend to others’.

Is the service well led?

There is no registered manager at the service, this is because the registered provider and the manager.

We asked the manager about how they ensured reviews of care plans were taking place. The manager told us there was a senior member of staff who undertook all the reviews and had records relating to when people's care plan reviews were due. We asked to look at this during our inspection however the manager was unable to locate it.

Staff were kept up to date with current polices because the manager told us the staff were encouraged to review the policy file and this was kept accessible in the office for the staff team.

We spoke with five staff members, we received mixed feedback about the management of the service. Comments received were, “They should treat everyone the same but they don’t. Some staff get away with murder. I am not supported at all”, “[Named manager] is alright I have no problems she is supportive in some ways”, “They are good, flexible and will help you out whenever. They [management] are always there to help you, we try and work as a team to try and provide the best care to the clients”.

The majority of the people we spoke with who received a service from Helping Hand were positive about their experiences and the comments received reflected this. One person told us, "If any of my friends said they needed help I would recommend them, they are brilliant". Another person told us, "We are generally happy, the carers are caring, competent and willing".

People who used the service were not fully protected from the risk of abuse, because the provider had not taken reasonable steps to safeguard people receiving care. Appropriate risk assessments were not in place for people. The staff we spoke to all told us they were aware of safeguarding procedures but staff training records showed that a lot of staff had not received training in this area for a number of years.

The people who used the service were very complimentary about the care staff that provided their service. We talked to a number of staff and they all felt as though they were offered enough support and opportunities to undertake training.

The provider had an effective system in place to identify, assess and manage risks to the health and safety of people using the service and others.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. One person who used the service told us that their care plan had been missing for a number of weeks and the care plans we looked at were very task focused.

People who use the service told us they were happy with the support they received and said they were in involved in decisions about how it was provided. One person said ““When I first needed care in my home I had several different agencies coming, I chose the one I liked best which is Helping Hand".

We found that people were very happy with the care workers who visited them and that they were competent in their role, one person stated, ""I wouldn't change them (Care workers) for anything, my key-worker is absolutely superb".

People also knew how to comment on the service they received and felt that any suggestions or improvements were acted upon by the management of the service.

We spoke to the owner/manager, staff in the office, staff and people who use the service by telephone. Comments we received were generally positive and included, "I have had them for years and never been let down. "Also, The carers are on time and do not come late late." A member of staff spoken to said, "A lot of staff have been here for years, that is a good sign."

Staff members we spoke to told us they thought it was a good agency to work for.

Comments included, " We get along and cover for each other in busy times." Also, "The owner is supportive and helpful.".

Other professional agencies we spoke to, such as Lancashire social services said they

have no issues with the agency. They told us they have not been involved in any safeguarding incidents. However, some staff told us they have not received safeguarding training for a long time. One staff member spoken to said, "I have not had abuse training for a while." The owner recognised they do need to update staff knowledge around safeguarding issues to ensure people are aware of any signs of abuse and know the procedure to follow.

Staff spoken to had a good awareness of individuals care needs and the importance of

treating people with respect and dignity. This was confirmed by training provided by the owner around respect and dignity and talking to people who use the service.One person said, "When they come in my home they are always polite and respectful."

We undertook an inspection on 2 and 12 October 2015 this was an announced inspection. This meant the provider was given 24 hours’ notice that we were coming. We carried out a comprehensive inspection and followed up on the enforcement action related to previous breaches that had been identified during our last inspection.

Helping Hands Domiciliary Care Service is registered to provide personal care for older people in their own homes. The service is operated by an individual who also manages the services on a day to day basis. There was no requirement by the Commission to have a registered manager in place for the service.

We previously visited the service and identified several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to; safeguarding, staff recruitment, safe administration of medicines, managing risk, staff training, supervision of staff, records, complaints and monitoring the quality of the service, We took enforcement action against the provider and told them the date by which they had to take action to ensure they made improvements We also issued two recommendations relating to staffing and appropriate training relating to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). We followed these up during this inspection. On this inspection we found that improvements had been made in all areas.

People using services and their relatives told us that they felt with the staff who delivered their care. We were told, “I have no concerns about the service or the staff and if I require them I only have to ring the office” and, “I have two carers each visit and I feel safe with them in my home.” Staff were able to discuss the appropriate actions to be taken if abuse was suspected and they confirmed they had received recent safeguarding training.

The provider showed us the safeguarding file and we saw evidence of safeguarding investigations which included notes on the investigations. We discussed with the provider their regulatory responsibility to notify the commission of any safeguarding allegations. Following our inspection the provider sent the appropriate notification to the commission.

We looked at a number of staff files and saw improvements had been made to the recruitment process. Evidence of application forms including notes taken from the interview were seen along with reference for the provider to assess the suitability of each candidate. Appropriate checks taking place were evident in staff files along with documentation to confirm people’s identity. Staff we spoke with confirmed there was enough staff to meet people’s needs.

We asked the provider about how they monitored risk in the service. The provider told us the care plans and risk assessments were being reviewed every one to three months by the care team supervisor. The care files we looked at contained evidence of risk assessments in place.

During this inspection we noted improvements in medication administration, however there was still gaps in the recording on the Medication Administration Record (MAR). The provider told us they were auditing the MAR charts when staff returned them to the office; however they were not recording this. Staff we spoke with confirmed they had undertaken medication training recently. One person told us, “A pharmacist came in and showed us how to complete the MAR sheets.” Management we spoke with said, “Medications are our main focus until we can relax. It’s ongoing.” People using the service were confident in the skills demonstrated by staff in their medication administration, they said, “They give me my medication from the blister pack and make sure that I take the tablets before they go. I have no concerns about the service or the staff.” We have made a recommendation that the provider should access relevant NICE guidance for the safe administration and recording of medications.

We spoke with people who used the service; they told us staff treated them with dignity and respect when visiting their homes. People confirmed staff asked for their permission before carrying out any activity.

We looked at six care files and saw evidence of consent documented in them.

We asked about the training staff received from the provider. Staff told us they had received recent training that was relevant to their role and we saw evidence of this in the training matrix and in staff files we looked at. The provider showed us a supervision file that contained details of recent supervision that had taken place. Staff confirmed supervision was taking place regularly and had been undertaken recently.

We received positive feedback about the quality of care offered by the staff team. People said, “The visits are about me. The carers are very kind and caring, they talk to me all the time, they treat me with dignity and respect and allow me to be independent when carrying out personnel tasks. My care is about me”. Staff were able to discuss the needs of people using service and had an understanding of their role.

We looked at six peoples care files and saw improvements had been made in them. Care plan were details and provided staff with information on how to meet people’s individual needs. Risk assessments were up to date and there was evidence of reviews taking place. All care files indicated a preadmission had taken place prior to any care delivery.

We saw a complaints file which indicated any complaints received by the provider and included actions and the outcome taken as a result of their investigations. We saw some positive feedback about the service and people using services were happy with the care they received from the staff.

We noted considerable improvements in audits and monitoring had taken place by the provider. Audits were taking place regularly and there was some evidence of the actions taken as result of the findings. The provider demonstrated an understanding of their role in ensuring the quality of the service was maintained. They said, “We are continuing to make improvements, keeping everything up to date. We talk to the staff constantly focussing on the five domains. We have improved the rotas. We look for new ways of doing things such as using social media for feedback.”

Staff confirmed team meetings were taking place and we saw evidence of team meetings minutes that included attendees and topics covered.

Staff gave positive feedback about the management and told us they felt confident to raise concerns with them. Staff told us, “Things have got a lot better. They (The office) have been communicating. We discuss our problems and they have been listening to us. It’s brilliant.”  We received mixed feedback about the management arrangements for the service from people using services and their relatives. Professionals we spoke with about the service also had mixed views. People said that on the whole the provider was responsive to changes in care they had been advised about, however one person told us about an occasion where the staff had not followed guidance offered by them. We spoke to the provider about this who discussed these concerns and the actions they had taken as a result of this.