Monitoring Form. Community based services. Safeguarding Assurance & Quality Services. Organisation. Service Manager. Service Type

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1 Monitoring Form Community based services Safeguarding Assurance & Quality Services Organisation Marygold Care UK Ltd Service Name Marygold Service Manager Angela Lumphezi Banda Service Type Care in the home SQA representative Cathie Moore Type of Visit Announced Date of Visit 3/7/15

2 Analysis of compliance for Marygold Percentage of Criteria Met/Not Met 100% 80% 60% 40% 20% 0% Criteria Not Met Criteria Met Key Line of Enquiry Key Line of Enquiry. 1. Safe 80.00% Good 2. Effective 80.00% Good 3. Caring 80.00% Good 4. Responsive 80.00% Good 5. Well-led 80.00% Good Outstanding - 5 The service complies with all requirements included within the Quality Charter at an outstanding level. The service also meets all requirements specified within the key line of enquiry and can evidence excellent performance in this area. Good - 4 The service adequately meets the requirements and has additional measures in place that demonstrate good working practice, with reference of working towards the expected standards contained within the Quality Charter. Meets standards - 3 The service is generally satisfactory and meets the basic requirements with some improvement necessary. Further evidence is required to demonstrate the incorporation of the Quality Charter in their practice. Requires Improvement 2 The service does not adequately meet the basic requirements and there are greater areas for major improvement necessary. The Service is unable to demonstrate full commitment to the Quality Charter in their practice. Inadequate - 1 The service does not meet the basic standards and needs to take immediate action to rectify this. The service shows no commitment to the Quality Charter and urgent improvement is require Page 2 Safeguarding Assurance & Quality Services Monitoring Form

3 Wellbeing Principles Protection from abuse and neglect. Physical and mental health and emotional wellbeing. SECTION 1: SAFE Criteria Score 1-5 Total Comments There are sufficient staff on duty to ensure safe and effective service delivery at all times taking into account service users need. 4 4 The provider is relatively new in Harrow and is in the process of building up its business. There are 2 service users and 1 pending. The provider has a large base of workers that are registered with them but is only actively working with 4 staff at the moment until more packages come on board. At the present time there is sufficient staff to cover the workload with room to expand when needed. Staff are regularly supported and appraised in their role through supervisions, appropriate training and continuous development. 4 8 Page 3 Safeguarding Assurance & Quality Services Monitoring Form The manager meets regularly with the small staff team both in the field and one to one. There was evidence of a 3 monthly appraisal and supervisions record on file, further training had been identified through the supervision process. All staff have undergone the induction process which is carried out by the manager. On-going training is carried out using on line products and through external trainers for specific accredited and practical courses, e.g. first aid. The staff have not yet had practical hoist training, the manager stated that this would be organised when the need arises. At the moment there is no central record for supervision and training of staff, the provider was able to demonstrate future plans to put these in place using a database system specifically designed for the care industry and staffing plan to employ field workers and senior staff to take on part of this role.

4 Staff files are up to date with the correct documentation to safeguard service users from unsafe working practices. Does the service follow clear staff disciplinary procedures when it identifies that staff are responsible for unsafe practice? The staff files were well maintained and in good order, with a completed application form and rights to work, each person had a DBS check on file, references need to be more robust, the provider should where ever possible request references direct from employers/ colleges and have a company stamp/headed paper,rather than from the care worker themselves. The manager supports staff through shadowing and close supervision, where an issue arises the manager will go into the service user with the care worker and work through issues. No staff have needed to be disciplined to date, however, the agency has policies and procedures in place which have been purchased off the shelf and adapted to fit within the needs of Marygold Care. The provider has signed up with Peninsula for HR support. The provider keeps up to date with policies and procedures through monthly newsletters from Agora business, and through UKHC, this is passed on to staff at regular meetings, long term plan for the service is to have a regular newsletter in place which updates staff on latest information. The provider will have a Safeguarding Adults policy and procedure in place Staff have access to and an understanding of safeguarding policies and procedures including 4 24 when, how, where and to whom to make a safeguarding referral. Information on safeguarding is made available to service users, families or 4 28 visitors. Page 4 Safeguarding Assurance & Quality Services Monitoring Form The provider has a policy in place, this needs to refer to the pan London safeguarding policy which Harrow has signed up to. Staff are trained at induction. The provider should utilise training from Harrow Council, this is free and follows the Pan London procedures. Each file contains information on safeguarding, this is kept within the service user home and can be is accessed by the service user, their representative and the staff.

5 The provider must ensure that staff employed to undertake regulated activities have DBS checks in place A record of safeguarding referrals is maintained Not scored Not scored Risk assessments are completed in line with care/support plans, outlining identified risk and relevant 4 36 preventative measures. All actively working staff have a current DBS check; this was evidenced on the staff files. The provider has no safeguarding referrals to date but is aware that any such incidents should be logged. Risk assessments were in place; these were carried out by the manager of the service and covered both the care delivery and the environment. Strategies are in place to manage the identified risk 4 40 The provider had put in place a plan of care delivery derived from the completed risk assessments. Care plans and risk assessments are reviewed and updated within appropriate timescales and/or where changes to individual needs are identified The care plans and risk assessments are reviewed regularly, the provider plans to have a risk assessment based criteria which will determine how often reviews will take place, using two reviews a year as the standard and increasing for those with high needs/complex care. A review will still take place where a need is identified. Total Score 44 /55 Page 5 Safeguarding Assurance & Quality Services Monitoring Form

6 Wellbeing Principles Individual contribution to society Personal dignity Control by the individual over day-to-day life. Social and economic wellbeing SECTION 2: EFFECTIVE Criteria Score 1-5 Total Comments Assessment documentation confirms the provider can meet all needs of the service user prior to service delivery. 4 4 The service makes sure that people are well matched with staff, to make sure they are compatible. 4 8 The manager carries out the initial assessment with the service user and their representative prior to taking on a care package. The assessment documentation has sufficient detail that demonstrated meeting the needs of the individual through risk assessment, care planning, establishing the care needs and service delivery required by the individual. Whilst there is a small number of service users, the manager has been able to match staff from similar backgrounds to service users. The manager has followed up with the service user and staff member to confirm compatibility. An induction programme is in place for staff which is aligned to the Care Certificate framework and relevant and appropriate to their role in the Service 4 12 The provider has recruited staff who have specific Asian language skills common in the borough. There is an induction process in place, which is delivered by the manager and based on the UK homecare association handbook which the organisation have purchased through skills for care. The new starter is then introduced and shadowed with service users. Each staff member had a three month appraisal on file. The provider is aware of the care certificate and will be working towards this when inducting new staff. Page 6 Safeguarding Assurance & Quality Services Monitoring Form

7 The MCA has been considered and acted upon where applicable How are service users nutritional needs, including those relating to culture and religion identified monitored and managed? To ensure a holistic approach to care delivery the service engages with a range of relevant health professionals and agencies to maintain service users health and access to services. Total Score 24/ The provider should establish the service user s mental capacity and record this on the care plan, if the service user does not have capacity, it should be clear who will support them to make decisions. All current users have capacity. The provider notes information on nutritional needs including cultural foods on the care plan. The provider demonstrated how this worked in practise as she was able to match a service user from Romania with a care worker who was able to prepare ethnic specific food. The provider was able to demonstrate that they report to care management service user s issues and concerns as one service user has issues with her accommodation which the manager referred back to care management. Generally the current users are all able to manage their own health needs but the provider when asked was clear that she would involve relevant professional if needed Wellbeing Principles Individual contribution to society Control by the individual over day-to-day life. Social and economic wellbeing Domestic, Family and personal relationships. SECTION 3: CARING Criteria Score 1-5 Total Comments Staff should know the people they are caring for and supporting, including their preferences and personal histories. 4 4 Staff are introduced to service users initially with the manager, the same group of staff stay with each service user allowing them continuity and building up of relationship. There is also a written care plan in each home which the staff can access. Page 7 Safeguarding Assurance & Quality Services Monitoring Form

8 Processes are in place for service users/families/carers/advocates to make representation about the quality of service as well as being kept up to date on relevant issues. Service users, family/carers and, where appropriate, advocates are involved in the care/support planning process from implementation through to review As there is a small number of service users at present the manager is able to engage with them regularly and gain feedback on a day to day basis, being kept up to date on any changes in service. The provider has plans to have a more formal quality assurance process and service user engagement programme in place once the service is more established. The manager meets with each new service user and their representative to establish the care plan and complete risk assessments, and includes them in the review process. The manager should agree the care plan with the service user/representative and ask them to sign their agreement. The service ensures people s privacy and dignity are respected and promoted How does the service make sure that staff know how to manage, respect and follow people s choices and wishes for their end of life care as their needs change? Total Score16 / Dignity and respect is highlighted through the induction process and through the manager introducing the care worker to the service user, it is backed up in the information provided to the service user and the staff handbook. The provider plans to launch a regular newsletter for staff in the future. Not scored Not scored The provider does not currently deliver end of life care, the next of kin information is recorded on the care plan with details of who to contact in an emergency. SECTION 4: RESPONSIVE Wellbeing Principles Personal Dignity Physical and Mental Health and Emotional Wellbeing Criteria Score 1-5 Total Comments Page 8 Safeguarding Assurance & Quality Services Monitoring Form

9 Care/support plans are person centred and based on service users individual views, wishes, feelings and beliefs What arrangements are there for people to have their individual needs regularly assessed, recorded and reviewed? The care plans were appropriately set out with a plan for care delivery, there was some basic information on service user s faiths and cultural needs, this section could be expanded to include some life history, interests and activities. The provider has put in place an outcome focused review, which was completed in April, this was a good document and focused on the individual s quality of life. Presently, the manager is able to spend plenty of time reviewing and updating individual needs and records. Once the business has built up, the manager has a plan to continue carrying out the initial visit and introduction of care worker, a follow up phone review after a week, and put in place a review plan based on dependency, high reviewed monthly, medium 3 monthly and low 6 monthly. A formal complaints procedure is available to all parties and complaints recorded appropriately with relevant outcomes. How are people given the care and support they need, in terms of their age, disability, gender, gender identity, race, religion, belief or sexual orientation? Total Score 16 / There is a formal complaint procedure which is included in the service user folder which is kept in the home, the provider should include the right for service user to complain to the funding authority The provider has an equalities policy in place and considers service users needs when matching care workers to service users SECTION 5: WELL-LED Wellbeing Principles Personal Dignity Physical and Mental Health and Emotional Wellbeing Page 9 Safeguarding Assurance & Quality Services Monitoring Form

10 Criteria Score 1-5 Total Comments Staff are supported to question practice and people who raise concerns, including whistle-blowers are protected. 4 4 Does the registered manager understand their responsibilities, and 4 8 are they supported, where appropriate, by the provider to deliver what is required? Are quality assurance systems effective, and are they used to drive continuous improvement? 4 12 Whistleblowing procedure are in place, the provider goes through the procedures with staff at induction and supervision The registered manager is also the provider and has a good understanding of the care industry, expectations and requirements. Although the business is currently quite small, the provider was able to outline clear business plans to support expansion within the organisation so that a good standard of care is maintained. The provider keeps up to date with policies and procedures through monthly newsletters from Agora business, and through UKHCA, this is passed on to staff at regular meetings, long term plan for the service is to have a regular newsletter in place which updates staff on latest information. As part of the quality assurance visit, I spoke with 1 service user, who was very happy with the service and agreed that the agency treated them with dignity and respect. Does the service have, and keep under review, a clear vision and a set of values that includes involvement, compassion, dignity, independence, respect, equality and safety? Are they understood and promoted by all staff? Are CQC registration requirements, including the submission of notifications and any other legal obligations, met? Total Score16 / The provider clearly sets out its aims and objectives in the service user guide which is provided to each new service user to be kept in the house. The provider needs to make sure that all documents have been reviewed and updated appropriately. Not scored Not scored The service is newly registered and not yet been inspected from CQC, there are no outstanding issues Page 10 Safeguarding Assurance & Quality Services Monitoring Form

11 ACTION PLAN Action To put in place a supervision and appraisal matrix to allow forward planning To put in place a training matrix for all staff so that there is a clear record of when training has taken place and when updates are due. To make reference to Pan London Safeguarding policy within the company s procedures and utilise local safeguarding training from Harrow. To establish mental capacity as part of the care planning and assessment procedure and record this on the care plan. To look at implementing induction in line with the care certificate for future employees. To make sure all documentation is regularly updated and a review date set including the service user information. The complaints information should include the rights of service users to complain to their funding authority if they wish. Risk/RAG rating Date to be completed by Evidence of completion Signature for sign off Date of sign off Form completed by: Cathie Moore 10/7/15 Signed off by SAQS Manager / Senior Officer : Page 11 Safeguarding Assurance & Quality Services Monitoring Form