This comprehensive inspection took place on 17, 24 and 25 November and 2 December 2016 and was announced.

The last inspection of this service was carried out in July 2015. At that time the provider was failing to meet the regulations relating to staffing levels, staff training and support, medicines management and effective quality assurance processes. The provider sent us an action plan showing how they intended to address these matters. During this inspection we found the provider had made improvements in all these areas.

Voyage Specialist Healthcare is registered to provide personal care to adults and children with complex needs in their own homes. At the time of the inspection there were 59 people in receipt of a care service.

The service had a registered manager who had been in post since December 2015. 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.’

People received their medicines in a safe way. All staff administering medicines had received up to date training and competency checks. Medicine administration records (MARs) were completed.

Staff levels and rota systems were monitored to ensure they were more efficient in the deployment of staff. The service had ongoing recruitment processes in place at the time of the inspection. The provider recruited staff in a safe way, ensuring all appropriate checks were completed prior to staff commencing work.

Staff received regular supervisions and annual appraisals to discuss their personal development and success in their roles. Staff had received up to date training in a number of areas and the registered manager had an ongoing training plan to ensure staff training was kept up to date. Staff also received specialist training specific to individual people, based on their needs.

The registered provider had a robust quality assurance system in place to monitor service provision and inform ongoing development and improvement.

Staff had a good understanding of how to safeguard people, including what potential signs to look out for with people and how to report any concerns. The registered provider had an up to date whistle blowing policy which they ensured staff were aware of through the induction process as well staff meetings and supervisions.

All risks to people's safety were assessed and monitored. All risk assessments had associated detailed care plans in place to guide staff how to support people to manage those risks safely.

People were supported to meet their nutritional needs with staff supporting them when required. People had appropriate nutritional care plans and risk assessments in place if they required support to maintain a healthy balanced diet as well as to support with specific dietary requirements.

People had access to a range of healthcare professionals and staff supported them to access them in a timely way.

People's needs were assessed shortly after admission to the service and details of their life history were included in care records. People's care plans were very detailed and personalised to each person and included details of preferences, likes and dislikes. Care plans were reviewed regularly and updated in line with people's changing needs.

In June 2012, we found that the service was not working effectively to support the people who used them. Whilst following up the issues we have spoken to a variety of people and staff. People have told us that the service has markedly improved. They told us that they had found that the provider had taken a range of steps to make sure they or their relative received prompt, timely and appropriate support to meet their care needs.

During this visit we checked that the provider had taken action to make sure an effective quality assurance process was in place and that staff were receiving the training they needed to deliver the care. The people we spoke with most recently said “My relative requires a lot of specialist support and I find the girls are very competent when dealing with all the equipment and their care needs”, “No service is ever faultless but the staff always check with me that it is ok and ask my views”. and “I find the staff go the extra mile to try and make sure everything runs smoothly”.

We found that the provider had developed systems to monitor the service; proactively involve the people who used the service in shaping how it ran; and ensure all of the staff were competent to undertake their different roles. We saw that the systems, which had been set up assisted them to check how well they were performing and to make improvements when needed.

The inspection took place because we were following up a warning notice issued in June 2012 in respect of how the provider met people’s care needs. Therefore when talking with people we concentrated on this specific area. We spoke with nine people who used the service and three relatives. People told us that they thought the staff were excellent at their jobs and really understood their or their relative’s needs. They said, ‘’The staff are absolutely fantastic’’, ‘’I find they always turn up on time and know how to look after my son’’, ‘’The staff are really attentive, I can’t fault them’’ and ‘’The carers who come are brilliant and if they are ever delayed they always give me a ring’’.

People told us that previously they had not always received the service they had expected and found that reviews were not regularly completed around how their care should be delivered. All of the people we spoke with said that improvements had been made to the service and they no longer found this to be an issue. All the people said that a senior staff member had visited them to discuss their care package and the intention was that monthly visits would happen thereafter. They told us that this made them feel that they were more in control of how the service was being delivered.

People said ‘’Now if I find that if I don’t gel with a carer, the managers really look at the situation and put things in place to resolve this’’, ‘’The carers always turn up now and if there is a problem I get plenty of notice plus a replacement carer’’, and ‘'There had been lots of problems but over the last few month they have gone out of their way to sort them’’, and ‘’When I raise issues these are dealt with straight away’’.

The visit took place because we were following up a warning notice issued at the last inspection in June 2012 in respect of how the provider handled complaints. Therefore when talking with people we concentrated on this specific area. We spoke with eight people who used the service and six relatives. People told us that they thought the staff were good at their jobs but discussed how they had needed to raise a number of concerns and complaints about staffing levels. Also people told us that at times the staff in the office did not follow good customer care practices when speaking to them. Most people said that they felt that this had started to improve. All of the people we spoke with told us that they had received copies of the complaints procedure and now found that if they raised a concern the provider responded to them in a timely manner. Some people told us that the provider had brought an independent person in to look at their complaint.

People said ‘‘I rang today to say the carer had not arrived and they apologised straight away for the error, which is new. They seemed to listen to me and I felt they were trying their best to sort it out, obviously they can’t magic people up but they do seem to be taking things seriously now’’, ‘‘There have been lots of problems and they seem to be getting on top of it but it is early days. However I now find that any concerns are dealt with straight away and they let you know what is going on’’ and ”After repeated complaints never getting addressed I was pleased to find that the new director has taken a different approach and got an independent investigator in. The investigator has spoken to me and told me exactly how they will look into the issues I have raised and when I will get feedback’’.

During our inspection we spoke with 3 people using the service and five relatives, four of which were parents of children receiving care from Partners in Specialist Care.

Some people told us they were happy with the care provided. For example, people told us:

"I get the same staff and they are all very polite."

"I get a choice in terms of staff."

"We have 4 weekly review meetings and 8 weekly multi disciplinary reviews. I have used the agency for 3 years. Care is unbelievable, I can’t sing their praises more highly."

"I absolutely adore the agency, the staff are all fantastic. I have set regular staff, I have no input with employment but staff were introduced and I do have a choice."

However, other people raised concerns about the service. For example people told us:

"The agency change things, they don't respect that they are in people's homes not a hospital."

"Having a constant stream of new people seeing to your personal care doesn't maintain your dignity."

"Partners are out of their depth with the complex packages. I should get a monthly review but they are not happening."

"I have never had sufficient cover, as a result, this puts my carers under a lot of pressure to work outside their normal hours. I have had shifts where no-one has turned up, on one of those occasions, I was expecting a particular carer, no carer turned up; the on-call coordinator can see that nobody had logged in and would normally phone me and the scheduled carer. Nobody phoned all day."

"My permanent carers are great, the problems we have are due to insufficient staff being recruited by the agency."

"I have concerns about the package and their handling of it; I don't feel the carers are experienced enough.”

"There is a problem with sickness, we are given empty promises, we have complained about the management as it took four and a half months to reply to my last complaint."

"You raise concerns all the time but get nowhere."

We received a number of comments from people which include the following:

"The standard of care is ok, we were originally involved in discussions about the care plan".

"I am quite happy with the standard of care".

"I would like to be involved in the recruitment process with my son, he may not be able to speak but can still make decisions".

"I had concerns regarding the competency of staff but it's sorted now".

"There is no consistency in night staff, we get rota's but we don't get told if someone different is coming".

"Communication is very poor" and "We get surveys and have four weekly meetings; they check the care files and ask if we have any problems".

"I've not had any reviews or formal meetings".

"I would feel confident in raising any concerns".

This inspection took place over four days. The first visit was on 8 July 2015 and was announced. We returned to the provider on 9 and 13 July 2015, and visited people who used the service in their homes on 10 July 2015.

Innovation Centre is registered to provide personal care to adults and children with complex needs in their own homes. At the time of our inspection they were 36 people using the service.

We last inspected the service in February 2014. At that inspection we found the service was meeting all the regulations that we inspected.

This inspection took place over four days. The first visit was on 8 July 2015 and was announced. We returned to the provider on 9 and 13 July 2015, and visited people who used the service in their homes on 10 July 2015.

Innovation Centre is registered to provide personal care to adults and children with complex needs in their own homes. At the time of our inspection they were 36 people using the service.

We last inspected the service in February 2014. At that inspection we found the service was meeting all the regulations that we inspected.

No registered manager was in place at the time of our inspection. The manager advised us they had submitted their application to CQC to become a registered manager. 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We noted safeguarding concerns had been investigated and referred to the local authority.

We saw risk assessments were present in people’s care records and included pressure area care, medication and use of profiling beds. However the risk assessments were generic and identified the hazard and control measures and no reference was made to the person and their needs.

Procedures for managing people’s medicines were not safe as records were inconsistent. There were a number of gaps in the recording of the administration of topical medicine on the medicine administration records (MAR) we viewed. We noted in one person’s MAR we viewed in their home had not been completed for one full month.

We noted in the complaint logs 13 ‘service delivery failures’, one service issue and one missed call. One complaint detailed, ‘I'm so disappointed yet again to be informed today that my nightshift cannot be covered tonight, no explanation why or reason or offer of another night’.

We saw the provider had followed their recruitment and selection policy. Each file held two references with at least one from the previous employer and all staff had new Disclosure and Barring Service (DBS) checks prior to their employment.

We found that training and development was not up to date. Staff told us that they did not receive regular supervisions and appraisals.

We did not see evidence of Mental Capacity Act (MCA) 2005 assessments and ‘best interests’ decisions being carried out for people who lacked capacity to make decisions for themselves. The managing director showed us ‘best interest’ documents and told us the clinical case managers would be carrying out MCA assessments on those who needed assessing during their reviews.

Relatives we spoke to told us they had not been involved with reviews of their relative’s care for a number of months, recalling that the last time was with a staff member who has since left the organisation.

We found a discrepancy in the quality of the detail recorded in children’s care plans compared to adult care plans.

People and family members gave us positive feedback about the care workers providing the support. However relatives told us the management did not always listen to their needs.

We saw that a complaints policy and procedure was in place. People and relatives were aware of the complaints procedure.

The managing director told us the service was going through a transitional period and they and the management team were implementing a range of new practices across the service.

Relatives and people who used the service told us they welcomed the new management. One relative said, “I hope these are better than the last lot.” Another said, “Things need to improve, there is a lack of communication.” However, another said, “I don’t know who the management is, no one visits.”

The provider did not have an effective system in place to regularly asses and monitor the quality of the service provided.

We saw all policies and procedures were up to date with a clear process and review date in place.

The manager had been pro-active in submitting statutory notifications to the Care Quality Commission and had started the process of applying to become a registered manager.

During our inspection we identified a number of breaches in regulation; you can see what action we told the provider to take at the back of the full version of the report.