Date of assessment: 17 June to 17 July 2024. An assessment has been undertaken of a domiciliary care agency that supports people in their own homes. They also support autistic people or people with a learning disability in a supported living service. This service provides care and support to people living in a supported living setting, so that they can live as independently as possible. At the time of assessment, there were 121 people receiving support with personal care. Risks to people were managed safely and care plans guided safe practice. Staff understood their responsibilities for keeping people safe and promoted their choices and independence. Staff were recruited safely and had the skills and knowledge to meet people’s needs. People were supported to have choice and control over their lives and were involved in planning their care. The provider had oversight of quality monitoring and safety. Records were accurate and reviewed regularly. The provider encouraged feedback from people and staff and used this to shape quality assurance processes and make improvements. Although some concerns were raised by staff regarding feeling rushed between calls, ineffective communication at times and pressures on management, the registered manager was aware of this and people were unaffected. We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
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121 Care & Mobility Limited was rated Inadequate overall following inspections in June and July 2018, with five regulatory breaches identified across safe, effective and well-led domains including unsafe medicines management, inadequate risk assessments, MCA non-compliance, ineffective governance and failure to address breaches from the previous 2017 inspection. The service was placed in special measures, with staff kindness and safe recruitment practices noted as isolated strengths amid pervasive systemic failures.
Concerns (15)
criticalMedication management: “We saw a carer apply a daily patch to the persons shoulder... 'We put the patch on for (husband) as it's too fiddly, but there's no MAR chart.'”
criticalCare planning: “16 out of 300 plans had been revised. At this rate of progress, care plans would not be completed within the timescale set.”
criticalSafeguarding: “A safeguarding vulnerable adults action plan had been generated... 10 actions assigned to 121 Care & Mobility Ltd and at the time of the inspection none had been added to the care plan.”
criticalRecord keeping: “Care plan stated 'X has become doubly incontinent since the last assessment'. Then later it stated 'X goes to the toilet independently'. No further guidance for staff.”
criticalGovernance: “One person's MAR sheet audit dated 06 April 2018 stated 'No further action required' but had failed to identify errors made by staff in the administration of medicines.”
criticalConsent / capacity: “We spoke to one senior staff member about completing capacity assessments and were told that staff would not do them and that they would need a doctor to complete an MCA assessment.”
criticalStaff training: “'The two who were here two Saturdays ago didn't know what to do. The slings were put outside the arms instead of inside... they said they hadn't been trained to use one.'”
criticalIncident learning: “Actions taken had failed to demonstrate organisational learning by addressing the underlying issues, potentially leaving people at further risk of harm.”
criticalLeadership: “The provider and registered manager had not managed risk or made changes at a systemic, rather than reactive level.”
moderateStaff competency: “One relative said carers seemed 'Thrown in at the deep end'. One girl said, 'I sat in a classroom for a few days and now I'm out on a call'.”
moderatePerson-centred care: “Care plans contained basic information about care and support tasks. There was little additional detail about people's lives, protected characteristics, interests or personal histories.”
moderateEnd-of-life care: “No mention of end of life care, reference to a life limiting medical condition or any reflection of the person's religious practices or cultural considerations.”
moderateInfection control: “Person's needs had changed and support increased to include meal provision. However, risk assessments and care plans had not been updated and staff were using the soiled kitchen.”
moderateCultural competency: “People's sexuality, religion or cultural support needs were not recorded as part of their assessment; this left them at risk of discrimination.”
minorCommunication with families: “Two staff discussing the reasons for the delay across the front garden boundary fence... did not seem to be concerned that the visit was on public display where sensitive information could be overheard.”
Strengths
· People consistently described staff as kind, caring and respectful: 'They are brilliant, really kind and thoughtful'.
· The provider followed safe recruitment practices and maintained sufficient staffing levels to meet people's needs.
· Staff were provided with appropriate PPE and had received infection control training.
· Complaints were logged, investigated and outcomes reported to complainants; 10 complaints and 20 compliments recorded since August 2017.
· The registered manager introduced drop-in days, regular staff meetings, newsletters and improvements to staffing structure and accountability.
Quality-Statement breakdown (23)
safe: Risk assessment and managementInadequate
safe: SafeguardingInadequate
safe: Medicines managementInadequate
safe: Infection controlRequires improvement
safe: Incident learningInadequate
safe: Recruitment and staffing levelsGood
effective: Needs assessment and evidence-based toolsInadequate
effective: Staff training and competencyInadequate
effective: Nutrition and hydrationRequires improvement
121 Care & Mobility Limited was rated Requires Improvement overall following a February 2017 inspection, with two regulatory breaches found: inadequate risk assessment guidance for staff (Regulation 12) and ineffective governance audits failing to identify care shortfalls (Regulation 17). Effective, caring and responsive domains were rated Good, reflecting competent and kind staff, but weaknesses in office communication, managerial oversight and care plan risk documentation undermined safety and leadership ratings.
Concerns (8)
criticalCare planning: “a person with epilepsy was having a bath call, no reference had been made to the risk to the person in the event that they suffered a seizure whilst bathing.”
criticalGovernance: “Audits and systems were in place to monitor the quality of care people received but these had not always been effective in identifying shortfalls in people's care.”
moderateRecord keeping: “Audits of care records had not identified where there were gaps in risk information.”
moderateCommunication with families: “many said they were often not told about changes to their times or carers. When they rang the office and left messages staff rarely rang them back.”
moderateSupervision / appraisal: “supervisions had not picked up or addressed staff feelings of being unsupported.”
moderateSafeguarding: “Another member of staff told us they had now reported a safeguarding issue twice because they had received no feedback from office staff as to what action had been taken.”
moderateLeadership: “The registered manager was unaware of some of the issues people had raised with us and this made her aware of how with the expansion of the service her role had changed.”
minorIncident learning: “People who said they had completed surveys in the past said they had never received feedback regarding whether specific comments they had made or learned how theirs and other peoples comments were helping to shape the development of the service.”
Strengths
· Medicines were managed appropriately with MAR chart audits, shadowing of newly trained staff, and competency checks by senior staff.
· Staff received comprehensive induction based on the Skills for Care Certificate including shadowing, training courses and knowledge tests.
· People had their needs met by sufficient numbers of staff and the service maintained an ongoing recruitment programme.
· Staff demonstrated understanding of safeguarding procedures and different types of abuse.
· People were treated with dignity and respect; staff were described as kind, caring and friendly.
Quality-Statement breakdown (16)
safe: Risk assessment and care planningRequires improvement
121 Care & Mobility Limited improved from Inadequate to Good across all five key questions, successfully exiting Special Measures by addressing all previous regulatory breaches including risk management, care planning, staff training, consent recording and governance. The service demonstrated sustained improvement with person-centred care, robust quality assurance and positive feedback from people, relatives and professionals.
Strengths
· All previous regulatory breaches (Regulations 9, 12, 17, 18) addressed and met since last inspection rated Inadequate
· Person-centred care plans reviewed, accurate, and co-produced with people and relatives
· Staff well-supported through induction, training (including complex conditions), supervision and new mentoring system
· Robust quality assurance systems including medication, equipment and infection control audits
· Positive feedback from people, relatives, staff and external health and social care professionals
Quality-Statement breakdown (21)
safe: Assessing risk, safety monitoring and managementGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Learning lessons when things go wrongGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
caring: Dignity, respect and privacy
Good
caring: Promoting independenceGood
responsive: Person-centred care planningGood
responsive: Complaints handlingGood
responsive: Feedback and service developmentRequires improvement
well-led: Quality assurance and auditingRequires improvement
well-led: Communication with people and staffRequires improvement