Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection report Domiciliary care agency Elliotts Hill Care Limited (DCA) Great Elliots Hill Crowhill Road Haverfordwest SA62 6HT Date of publication- 24 th December 2011 You may reproduce this Report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers.
Care and Social Services Inspectorate Wales South West Wales Government Buildings Picton Terrace Carmarthen Carmarthenshire SA31 3BT 01267 245160 01267 245140 Name of agency: Elliotts Hill Care Limited (DCA) Contact telephone number: 01437 764720 Registered provider: Registered manager: Category: Elliotts Hill Care Limited Thomas Benjamin Hale Agency>200hrs Dates of this inspection episode from: Dates of other relevant contact since last report: Date of previous report publication : Inspected by: Lay assessor: Other regions contributing to this report: 22 August 2011 Marie Stirling N/A N/A to: 8 December 2011 Page 1
Introduction Elliots Hill Care Ltd was registered as a large domiciliary care agency and was jointly owned by Mr and Mrs Kelso. Mrs Kelso was very experienced and was the Responsible Individual. Mr Tom Hale was the registered manager. He was well qualified and experienced having attained NVQ Level 4 and was registered with the Care Council for Wales. The agency operated from purpose built well equipped premises at Crowhill Road on the outskirts of Haverfordwest Pembrokeshire. Elliots Hill Care Ltd provided a service to adults and children over the age of 10 years. The majority of service users who received a service from Elliots Hill Care Ltd had a learning disability with complex needs and challenging behaviours. Summary of inspection findings: What does the service do well? A comprehensive induction programme was completed by all new staff. The range of ongoing appropriate training was a high priority within the agency. Up to date policies and procedures were available to all staff as working documents. Clear care plans and risk assessments were available in each service users home and had been reviewed as required. Friendly supportive relationships existed between support workers and service users. What has improved since the last inspection? The agency had reviewed and updated its Statement of Purpose. Service users risk assessments and care plans had been reviewed. The introduction of area coordinators to support the management team. The introduction of a human resource manager and operations coordinator to support the management team. What needs to be done to improve the service? a.) priorities No requirements were made following the inspection episode. b.) other areas for improvement None following the inspection episode. Inspection methods Information for the inspection episode was gathered from the self-assessment of service (SAS) document and an annual data collection (ADC) form which had been completed by the registered manager. Both documents gave an overall picture of what had been achieved since the last inspection and what needed to be addressed to improve the service. The methodology of the inspection process included: Two un-announced visits to the agency office. Case tracking of identified service users was used as an assessment tool, this involved looking at how individual assessments were used to compile care plans and how the written care plan informed the actual care being delivered. Visits to service users homes. Page 2
Feedback from service users and their representative. 10 Questionnaires were distributed to staff and eight were returned within the timescale. Page 3
User focused service Inspector`s findings: The agency Statement of Purpose and Service Users Guide were informative and comprehensive. They had been reviewed and were up to date. Both documents were well written and presented. They provided clear relevant information to prospective and current service users, including the process of making a complaint and contact telephone numbers in the event of emergency. The service user guide was presented in two formats. One was written in an easy read format for the benefit of service users. Four files of service users were examined in the agency office. Where service users received funding from the local authority relevant assessment documentation, care plans and risk assessments were contained within the service user files. Where service users purchased care privately from the agency the file contained evidence that a needs assessment was undertaken prior to the commencement of care. Clear care plans were available in each service users home. These identified specific care needs and outcomes for service users. Appropriate risk assessments had also been carried out. There was evidence that service users who were visited had their care needs reviewed regularly, any changes to care provided was clearly recorded. Support staff reported any changes to care needs promptly to management. All daily records observed were clearly written and signed by the support worker. Service users spoken with were satisfied with the quality of support they received and the manner in which care was delivered. It was observed that friendly supportive relationships existed between support workers and service users. Internal quality assurance visits were made by the area coordinators, team leaders and the registered manager on a regular basis to service users homes. Requirements made since the last inspection report which have been met: When completed Requirements which remain outstanding: (previous outstanding requirements) Original timescale for completion New requirements from this inspection: Timescale for completion Good practice recommendations: Page 4
Personal care Inspector`s findings: A confidentiality policy was in place and available in the agency office. The staff induction programme and the Code of Conduct for staff included confidentiality. Information gained from discussions with staff and the return of questionnaires evidenced awareness and the importance of confidentiality. The inspector observed that service user records were stored appropriately and in accordance with requirements at the agency office. Daily records were maintained in the homes of all service users visited. These were clearly written and kept in good order within designated files. All records observed were signed by the support worker. Daily records related closely to care plans that were maintained in the service user s home and any changes to care plans were clearly identified. Requirements made since the last inspection report which have been met: When completed Requirements which remain outstanding from this inspection cycle: (previous outstanding requirements) Original timescale for completion New requirements from this inspection: Timescale for completion Good practice recommendations: Page 5
Protection Inspector`s findings: Elliots Hill Care Ltd had comprehensive health and safety policies and procedures in place for the protection of service users and staff. Documentation was well written, broad in scope and provided specific direction for staff. Health and safety, moving and handling, use of equipment, and risk assessments were included in induction and initial training, and staff received regular updates. Discussions with the registered manager and staff evidenced that training was taken very seriously and they had access to a range of appropriate training concerning the protection of service users. It was pleasing to note that service users files examined contained clear comprehensive risk assessments that had been reviewed on a regular basis. Environmental risk assessments were undertaken in addition to personal risk assessments. Members of staff were issued with protective clothing, including aprons and gloves and an infection control policy was in place. Policies and procedures were in place with regard to lone working arrangements. All staff wore identification badges, which they were instructed to wear at all times and were required to return to the agency on termination of their employment. CSSIW had been informed of adult protection issues that had been raised by the agency in the last inspection year. The management had responded appropriately to the issues identified and communicated effectively with the Local Authority and CSSIW to ensure good outcomes for vulnerable service users. Requirements made since the last inspection report which have been met: When completed Requirements which remain outstanding: (previous outstanding requirements) Original timescale for completion New requirements from this inspection: Timescale for completion Good practice recommendations: Page 6
Managers & staff Inspector`s findings: Elliots Hill Care Ltd was jointly owned by Mr and Mrs Kelso with Mrs Kelso being the Responsible Individual. Both were actively involved in the day to day running of the agency. Mr Tom Hale was the registered manager. He was well qualified and experienced having attained NVQ Level 4 and was registered with the Care Council for Wales. To support management and oversee the smooth running of the agency a human resource manager, operations coordinator, two area coordinators, seven team leaders, occupational health and safety manager, full and part time trainers and administrators were employed. At the time of inspection Elliots Hill Care Ltd employed in excess of one hundred and fifty (150) support staff. Recruitment procedures was discussed with the registered manager who confirmed that all the required checks including CRB checks were completed prior to the commencement of employment. Discussion with the new human resource manager confirmed that her role would include supporting the registered manager in the recruitment and retention of staff and ensuring the required procedures would continue to be followed. A comprehensive induction programme was completed by all new staff. Discussion with the registered manager and staff indicated that all support staff employed at the agency had completed up to date training in Health and Safety, First Aid, Manual Handling and Adult Protection. Specialist needs led training was available to staff members, for example, epilepsy, diabetes, mental health and pressure care. The registered manager confirmed that training in specialist areas was provided on an on-going basis to meet individual service user s needs. Over 50% of the staff team had attained or was in the process of gaining NVQ 2 or above. There was a well equipped training facility on site. The contact between support staff, team leaders, area coordinators and the registered manager was frequent. This enabled any changing need to be reported quickly and also offered support to support staff. Regular support staff meetings and management meetings were held which enabled effective communication. Discussion with support staff and questionnaires that were given to support staff during the inspection confirmed that regular supervision at the required intervals had taken place. Requirements made since the last inspection report which have been met: When completed Requirements which remain outstanding: (previous outstanding requirements) Original timescale for completion Page 7
New requirements from this inspection: Timescale for completion Good practice recommendations: Page 8
Organisation and running of the business Inspector`s findings: Elliots Hill Care Ltd was registered as a large domiciliary care agency providing a service to adults and children over the age of 10 years. At the time of the inspection the agency was providing in excess of 3,000 support hours a week. The agency operated from purpose built well equipped premises which was secure and presented as well organised. The management structure in place had clear lines of accountability. Up to date policies and procedures were available as working documents. A comprehensive policy and procedure for handling complaints was in place and the record of complaints was examined. Two reported complaints been satisfactorily resolved within the agency. Quality assurance checks had been undertaken periodically by the area coordinators, team leaders and the registered manager. A report had been collated and was seen by the inspector. The information gathered was to be used for service development purposes. The inspection episode indicated that Elliots Hill DCA delivered effective services. There was no evidence of any difficulties with financial viability. Insurance cover was in place. Requirements made since the last inspection report which have been met: When completed Requirements which remain outstanding: (previous outstanding requirements) Original timescale for completion New requirements from this inspection: Timescale for completion Good practice recommendations: Page 9
A note on CSSIW s inspection and report process: This report has been compiled following an inspection of the service undertaken by Care and Social Services Inspectorate for Wales (CSSIW) under the provisions of the Care Standards Act 2000 and associated Regulations. The primary focus of the report is to comment on the quality of life and quality of care experienced by service users. The report contains information on how we inspect and what we find. It is divided into distinct parts mirroring the broad areas of the National Minimum Standards. CSSIW`s inspectors are authorised to enter and inspect regulated services at any time. Inspection enables CSSIW to satisfy itself that continued registration is justified. It also ensures compliance with: Care Standards Act 2000 and associated Regulations whilst taking into account the National Minimum Standards. The service`s own statement of purpose. At each inspection episode or period there are visit/s to the service during which CSSIW may adopt a range of different methods in its attempt to capture service users` and their relatives`/representatives` experiences. Such methods may for example include selfassessment, discussion groups, and the use of questionnaires. At any other time throughout the year visits may also be made to the service to investigate complaints and to respond to any changes in the service. Readers must be aware that a CSSIW report is intended to reflect the findings of the inspector at a specific period in time. Readers should not conclude that the circumstances of the service will be the same at all times. The registered person(s) is responsible for ensuring that the service operates in a way which complies with the regulations. CSSIW will comment in the general text of the inspection report on their compliance. Those Regulations which CSSIW believes to be key in bringing about change in the particular service will be separately and clearly identified in the requirement section. As well as listing these key requirements from the current inspection, requirements made by CSSIW during the year, since the last inspection, which have been met and those which remain outstanding are included in this report. The reader should note that requirements made in last year`s report which are not listed as outstanding have been appropriately complied with. Where key requirements have been identified, the provider is required under Regulation 23B (Compliance Notification) to advise CSSIW of the completion of any action that they have been required to take in order to remedy a breach of the regulations. The regulated service is also responsible for having in place a clear, effective and fair complaints procedure which promotes local resolution between the parties in a swift and satisfactory manner, wherever possible. The annual inspection report will include a summary of the numbers of complaints dealt with locally and their outcome. Page 10
CSSIW may also be involved in the investigation of a complaint. Where this is the case CSSIW makes publicly available a summary of that complaint. CSSIW will also include within the annual inspection report a summary of any matters it has been involved in together with any action taken by CSSIW. Should you have concerns about anything arising from the inspector`s findings, you may discuss these with CSSIW or with the registered person. Care and Social Services Inspectorate Wales is required to make reports on regulated services available to the public. The reports are public documents and will be available on the CSSIW web site: www.cssiw.org.uk Page 11