Care and Social Services Inspectorate Wales. Care Standards Act Inspection Report BLUEBIRD CARE (NEWPORT) Newport

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1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report BLUEBIRD CARE (NEWPORT) Newport Type of Inspection Full Dates of inspection 22 and 26 January 2018 Date of publication Thursday, 1 March 2018 Welsh Government Crown copyright You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or psi@nationalarchives.gsi.gov.uk You must reproduce our material accurately and not use it in a misleading context.

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3 Summary About the service The registered provider of Bluebird Care (Newport) is Bowmor Limited. Bluebird Care (Newport) is a franchise of Bluebird Care Franchises Ltd. Bowmor Limited trading as Bluebird Care (Newport) is registered with Care & Social Services Inspectorate Wales (CSSIW) to provide domiciliary care services to older people, people with physical disabilities, people with sensory loss / impairment, people with learning disabilities, people with mental health problems and people with dementia. A nominated responsible individual (RI) acts on behalf of the registered provider to oversee the management of the agency. The registered manager of the agency is Dean Jones. What type of inspection was carried out? We (CSSIW) visited the agency office on 22 January 2018 on an unannounced basis and carried out a full inspection. We considered the experiences of people who use the service, the quality of staffing and the quality of leadership and management. Information in this report was gained by: Visiting the agency office on 22 January Speaking with the registered manager, RI and staff members. Looking at four service user s care documents held at the agency office. Looking at three staff personnel files. Consideration of the agency s statement of purpose dated June Consideration of commissioner s report dated September Consideration of the agency s internal quality assurance systems. Consideration of the agency s annual customer survey dated December Examination of complaints log held at the agency office. Consideration of notifications and safeguarding referral/s regarding the agency. Visiting two service users in their own homes on 26 January 2018 and examining information held at their home. What does the service do well? We did not identify any specific areas of excellence that were above the practices determined by the National Minimum Standards for Domiciliary Care Agencies in Wales What has improved since the last inspection? At our last inspection in November 2016 we issued non-compliance in relation to Regulation 9 (1) (a) of The Domiciliary Care Agencies (Wales) This is because there was no registered manager at the service at this time. Dean Jones was registered with CSSIW as the agency s manager in November Therefore, we have concluded this

4 matter has been satisfactorily addressed. With regards to the isolated areas of non-compliance found at the last inspection concerning staff recruitment practices, people s service delivery plans and medication records. We found evidence during the current inspection to establish that these matters had been satisfactorily addressed. Further information can be found within this report. What needs to be done to improve the service? We did not issue any non-compliance notices following this inspection. We made recommendations to improve outcomes for services users in respect of: Information about the agency needs to be accurate and reflective of the service. The agency s statement of purpose was dated June The agency s staff training plan needs to clearly show that staff are suitably trained to perform their duties. Internal audits of service user s medication needs to be more robust. Staff need to use the agreed reporting codes on people s individual medication (MAR) charts. The agency needs to document what action/s are taken when medication has not been administered in accordance with individual plans. A plan to be commenced to demonstrate the frequency each member of the agency staff team receives supervision.

5 Quality Of Life People were satisfied with the services they receive. We spoke with service users and their relatives and considered their responses to the agency s annual satisfaction survey. We were told all the girls are lovely and I m always treated respectfully (by staff). We accompanied a care worker to visit service users in their own homes. We saw service users were at ease with the care worker. The staff member displayed an awareness of each service user s individual needs and preferences. They were able to speak with each service user about their family members and knew their individual likes and dislikes. Examination of people s care documents contained risk assessments which included the security of people s property. We saw the staff member removed their shoes on entry of each service user s home which demonstrated respect towards their property. People reported that generally, agency workers were familiar and reliable. The agency recognised the importance service users place on being assisted by regular carers at agreed times. Staff told us that in order to promote continuity, their rotas were devised in consideration of people s individual care packages and the location. One relative confirmed they usually knew who would be visiting their loved one and at what time. If changes did occur, people told us they would usually receive a courteously call from staff. The agency s customer satisfaction survey confirmed our findings. People were informed and consulted about their care delivery. Staff told us that each person received a visit from the agency to discuss their individual needs and preferences before a care package commenced. Staff reported the information was compiled into a pre-assessment document. People we spoke with confirmed a visit had taken place and they were consulted about their and/or their loved ones care delivery. We viewed a sample of people s service delivery plans. We found each plan contained sufficient information to direct care workers to assist and support people in accordance with their needs and preferences. We saw the plans set out what assistance was required from the care worker at each visit. We saw evidence to confirm that the plan was developed after consultation with service users and their relatives. The plans were consistent with local authority/local health board commissioner s plans. We found risk assessments in place to support residents and staff in the course of daily routines and lifestyle. Additional risk assessments were in place from associated professionals e.g. occupational therapists regarding safe manual handling plans and the use of equipment. People s care documents also contained risk assessments which included the security of service user s property. We saw that people s service delivery plans were routinely reviewed by the agency to identify any change in need and support consistent care delivery.

6 Quality Of Staffing People are safeguarded by the agency s recruitment practices. We viewed four care workers personnel files and found the agency had strengthened recruitment practices. We saw that the necessary pre-employment checks had been completed for each staff member. Individuals employment histories were checked, references had been sought and authenticated and copies of their personal identification had been retained. A commissioner s audit carried out in September 2017 reported that staff files contained adequate information to support the individual s fitness to conduct their role. We concluded that the shortfalls in recruitment practices identified at our last inspection in November 2016 had been addressed. Staff need to be trained and supported to perform their role effectively. All newly appointed care workers receive an induction in accordance with the Bluebird franchise. The registered manager told us care workers recruited following his appointment had received induction training accredited with Social Care Wales (The Social Care Induction Framework). Examination of care workers personnel files confirmed this. New staff completed a number of shadow shifts which provided an opportunity for them to work alongside more experienced care workers. We saw training certificates to show that new staff had attended the necessary training to carry out their duties. A copy of the agency s staff training plan showed five care workers training in moving and handling, medication, infection control, safeguarding, food hygiene, health and safety, first-aid and fire expired on 30 January We found the information in the plan was not clear and difficult to read. We spoke with the registered manager and queried the accuracy of the information. We were told that staff training was previously managed from the Cardiff office. The registered manager told us he was to audit staff training records as a priority. He gave his assurance that staff would receive the necessary refresher training to enable them to carry out their role. The agency is able to access a range of training within the franchise. The registered manager told us he is planning to oversee all future staff training at the Newport branch. We suggested a review of the staff training plan to ensure it accurately reflects care workers training and development needs. Examination of staff personnel files showed regular monitoring of staff s performance. We saw evidence of regular spot checks and competency testing for staff in safe medication administration and manual handling. We were told that since the appointment of a senior care co-ordinator in November 2017 the opportunity for staff to receive one to one supervision from a senior staff member had increased. Supervision provides agency staff the chance to discuss their work, training and development needs. Examination of individual staff personnel files confirmed this. The agency supports monthly supervision for all staff. We suggested a plan is commenced to demonstrate the frequency each member of the agency staff team receives supervision. The registered manager told us staff appraisals to consider each agency workers standard of practice would be conducted in February Staff meeting minutes showed they had not always been regularly conducted. Staff meetings provide an opportunity to update and inform agency workers about the service.

7 The agency had sent out questionnaires to staff to gain their views and opinions of the service. We were told this the agency conducts an annual staff satisfaction survey. We requested a copy of the report once the findings were complete.

8 Quality Of Leadership and Management Since our last inspection in November 2016 the agency had appointed a manager to carry out the day to day management of the service. Dean Jones was registered with CSSIW in November He is dually registered with Social Care Wales. People were satisfied that the agency would respond to their concerns. The agency s customer survey indicated people knew how to make a complaint and had access to the necessary contact details to do so. Service users and their family members told us they would be comfortable reporting any worries they might have to the agency. A service user told us they found the agency office staff were friendly and approachable. They told us the agency had been responsive to a previous request when they had asked that a care worker did not return to their home. Systems were in place to monitor the quality of the service however; robust auditing of people s individual records is needed to fully safeguard them. Quality monitoring for both agency staff and the service is conducted. There is a process of consulting with service users and their relatives about the care service on a regular basis. The outcome of an annual customer satisfaction survey is made available to service users. The agency provides a regular newsletter to inform people about services and staff members. The agency does not use an electronic monitoring system at this time. This means robust reporting needs to be in place to demonstrate the efficiency of the agency. Examination of service user records showed that staff record in people s daily notes the times each visit starts and ends. Staff told us that in order to provide more of an efficient service, the location of visits were regularly reviewed and travel times included. We were told that record audits looked at whether staff were punctual and stayed the full duration of the call. However; we did not see any evidence to demonstrate that regular audits of visits were taking place. We were unable to establish if the length of time visits lasted complied with individual care packages as we only spoke with limited number of service users. People have not been fully protected as medication records were not always accurate and fully completed. The agency supports some people with medication. Examination of service users medication administration records (MAR) identified instances where medication had not been given as directed. For one service user the chart indicated that one tablet (Calcium) had not been signed for by staff for four consecutive days to evidence administration. There was no information written on the person s MAR chart or within their daily notes to indicate any reason why the medication was not signed for. We saw evidence that the chart was audited by a senior member of staff. However; there was no record of what actions had been taken following identification of this shortfall and or any remedial actions to prevent reoccurrence. We reported our findings to the registered manager and asked for a future explanation. During a visit to a service user s home we identified a further example of medication not signed for or appropriately documented. Again, there was no written explanation to indicate whether the medication was taken or not. We reported our findings to the agency staff. Following the inspection, we were provided with information about the actions taken in each instance. This provided assurance that neither service user was adversely affected. However, we suggested more robust medication checks needed to be implemented to ensure people are fully safeguarded. We have identified this as an area for improvement.

9 Quality Of The Environment The quality of the environment is not considered as part of a domiciliary care inspection as people receive care in their own homes. A visit to the agency office found appropriate secure storage facilities were in place to carry out the functions of the agency.

10 How we inspect and report on services We conduct two types of inspection; baseline and focused. Both consider the experience of people using services. Baseline inspections assess whether the registration of a service is justified and whether the conditions of registration are appropriate. For most services, we carry out these inspections every three years. Exceptions are registered child minders, out of school care, sessional care, crèches and open access provision, which are every four years. At these inspections we check whether the service has a clear, effective Statement of Purpose and whether the service delivers on the commitments set out in its Statement of Purpose. In assessing whether registration is justified inspectors check that the service can demonstrate a history of compliance with regulations. Focused inspections consider the experience of people using services and we will look at compliance with regulations when poor outcomes for people using services are identified. We carry out these inspections in between baseline inspections. Focused inspections will always consider the quality of life of people using services and may look at other areas. Baseline and focused inspections may be scheduled or carried out in response to concerns. Inspectors use a variety of methods to gather information during inspections. These may include; Talking with people who use services and their representatives Talking to staff and the manager Looking at documentation Observation of staff interactions with people and of the environment Comments made within questionnaires returned from people who use services, staff and health and social care professionals We inspect and report our findings under Quality Themes. Those relevant to each type of service are referred to within our inspection reports. Further information about what we do can be found in our leaflet Improving Care and Social Services in Wales. You can download this from our website, Improving Care and Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW regional office.