The service is a care at home service registered to provide support to children and younger adults, including people who may have mental health, sensory impairment, eating disorder, physical disability or learning disability needs or autism spectrum. An inspection has been undertaken of a specialist service that is registered for use by autistic people or people with a learning disability. We assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group. At the time of inspection there were 6 people using the service and all of the people were receiving the regulated activity personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. A registered manager was in place. A registered manager is registered with the Commission and is legally responsible to ensure that the service is compliant with legal and regulatory requirements. At our last inspection, we identified a breach of legal regulation in relation to fit and proper persons employed. At this inspection, improvements had been made and the provider was no longer in breach of legal regulation. At this inspection we found the service was meeting the underpinning principles of Right support, Right care, Right culture. Systems were in place to provide safe, effective care and person-centred support to people. The provider, registered manager and staff team went above and beyond to help people achieve their goals and aspirations by building their confidence and breaking down barriers to increase independence. Staffing capacity was sufficient to ensure people's needs were met in a safe way. Improvements had been made to roster management and people received consistent care from staff they knew. Systems were in place for people to receive their medicines in a safe way. There were enough staff with the necessary skills, qualifications and experience to meet people’s needs. Staff were safely recruited. People were treated with kindness and compassion. Staff protected their privacy and dignity. Risk assessments were in place, and they identified current risks to the person as well as ways for staff to minimise or appropriately manage those risks. Records were up-to-date, detailed and reflected people's care and support needs. People’s mental capacity and ability to consent was taken into account. People and their representatives were involved in planning their care and support. There was evidence of collaborative working and communication with other professionals to help meet people's needs. Relatives and staff were confident about approaching the registered manager and management team if they needed to. Processes were in place to manage and respond to complaints and concerns. Systems were in place to monitor the quality and safety of the service.
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Include 'In' Autism, a small domiciliary care agency supporting autistic people, received an overall rating of Requires Improvement following a focused inspection of safe and well-led domains, maintaining the same rating as its previous inspection in December 2021. A breach of Regulation 19 was identified due to failure to review DBS certificates prior to staff commencing work, and quality assurance systems failed to detect this recruitment failing.
Concerns (3)
criticalStaff competency: “DBS certificates linked to the DBS Updating Service were not reviewed by the service prior to applicants starting work.”
moderateStaffing levels: “People were not always supported by a regular staff team. One relative told us, "At times we don't know who is turning up, sometimes agency staff who we don't know"”
moderateGovernance: “Systems to monitor and assess the quality of the service were not always effective. Quality assurance systems had not identified the failure within the recruitment process.”
Strengths
· Staff supported people to take part in activities and pursue their interests in their local area.
· The registered manager liaised with the local authority and undertook appropriate investigations when allegations occurred.
· The service worked in partnership with external healthcare professionals, demonstrating good knowledge around people's needs.
· The registered manager was passionate about supporting children with Autism and had won two national awards for work within the autistic and learning disability community.
· The service embraced the Accessible Information Standard with a range of formats available to support people to share their views.
Include 'In' Autism, a small domiciliary care agency for autistic people in Sunderland, improved from Inadequate to Requires Improvement overall, exiting Special Measures, with key failures remaining around COVID-19 testing compliance and governance systems failing to identify their own gaps. Care, responsiveness and effectiveness were rated Good, reflecting positive staff knowledge, person-centred practice and improved training, though care plans and risk assessments did not fully capture staff knowledge.
Concerns (5)
criticalInfection control: “Staff were not completing weekly polymerase chain reaction (PCR) tests... not all staff were completing weekly LFT. This placed people at risk of harm.”
moderateRecord keeping: “Staff were extremely knowledgeable about how to keep the person safe, but this information was not reflected within the documentation.”
moderateCare planning: “Care plans and risk assessments did not reflect this depth of information.”
moderateGovernance: “The issues relating to COVID-19 testing and monitoring of DBS checks had not been identified by them.”
minorStaff competency: “Documentation stated that all staff were checked monthly via the DBS updating service... we found one staff member had not received monthly checks.”
Strengths
· Registered manager was responsive to feedback and immediately made changes during the inspection.
· Staff were knowledgeable about the person's likes, dislikes and support needs, and supported a small consistent staff team.
· New training programme and thorough induction introduced; staff felt supported by the management team.
· Range of visual aid tools and communication formats introduced to capture children's voice and promote involvement.
· Regular supervisions conducted and spot checks completed to maintain standards of care.
Quality-Statement breakdown (17)
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyNot rated
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
effective: Ensuring consent to care and treatment in line with law and guidance
safe:Insufficient evidence to ratewell-led:Insufficient evidence to rate
This targeted inspection of Include 'In' Autism checked compliance with warning notices issued for breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance), finding some improvements but noting requirements only partially met in most areas. The overall rating remains Inadequate and the service continues in special measures, with outstanding concerns around medication audits, record-keeping, and embedding new governance systems.
Concerns (4)
criticalGovernance: “medicine audits were not routinely completed and discrepancies we found in recruitment files had not been identified”
criticalRecord keeping: “provider failed to maintain accurate, complete and contemporaneous records and have effective systems to assess, monitor and improve the quality and safety”
moderateIncident learning: “these need to be sustained and further developments were still needed. The requirements of the warning notice have been partially met.”
moderatePerson-centred care: “provider failed to seek feedback from children about their care and support, and how the service was run”
Strengths
· Individual and person-specific COVID-19 risk assessments created to support people with face masks
· New COVID-19 risk assessment for staff at greater risk introduced and used to deploy staff safely
· Provider designed a range of tools to capture children's voices
· New system introduced for monitoring documentation to ensure it was up to date and accurate
· Additional methods of communication with families introduced
Quality-Statement breakdown (4)
safe: Assessing risk, safety monitoring and managementNot rated
safe: Learning lessons when things go wrongNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsNot rated
safe:Insufficient evidence to rateeffective:Insufficient evidence to ratecaring:Insufficient evidence to rateresponsive:Insufficient evidence to ratewell-led:Insufficient evidence to rate
Include 'In' Autism is a newly registered domiciliary care agency supporting two autistic adults in the community; the service was too small and insufficiently operational for CQC to award ratings at this first inspection. The single identified concern was a brief staff induction programme, with no safeguarding concerns found and strong relative feedback throughout.
Concerns (1)
minorStaff training: “New staff had not completed an in-depth induction programme... it was brief. One staff member told us, "Induction was very brief, we went through some policies and procedures."”
Strengths
· Provider managed risks appropriately with detailed care plans and risk assessments guiding staff on supporting distressed behaviour
· Incidents of distressed behaviour reduced significantly as staff got to know people better
· Staff received good support and training; positive behaviour support and managing aggression training arranged following an incident
· Relatives gave highly positive feedback about staff skills, patience, and compassion
· Care plans were detailed, personalised, and developed with relative involvement
Quality-Statement breakdown (19)
safe: Assessing risk, safety monitoring and managementInsufficient evidence to rate
safe: Learning lessons when things go wrongInsufficient evidence to rate
safe: Systems and processes to safeguard people from the risk of abuseInsufficient evidence to rate
safe: Staffing and recruitmentInsufficient evidence to rate
safe: Using medicines safelyInsufficient evidence to rate
effective: Staff support: induction, training, skills and experienceInsufficient evidence to rate
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawInsufficient evidence to rate
Include 'In' Autism was rated Inadequate overall following inspections in December 2020 and January 2021, with warning notices issued for breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance), and additional breaches found in recruitment (Reg 19) and staffing/training (Reg 18). The service was placed in special measures due to widespread failures in infection risk management, record-keeping, staff training, governance, and operating an unregistered children's home, though some strengths were noted in staff culture, partnership working, and adult care planning.
Concerns (10)
criticalInfection control: “Generic risk assessments indicated that people being supported could not tolerate staff wearing a face mask. Staff had not assessed individual needs or explored alternative solutions such as clear face masks.”
criticalStaff training: “People did not receive care and support from suitably skilled and experienced staff. Some staff had not received training around people's specific needs. No specific training regarding the care and support of children was in place.”
criticalRecord keeping: “The provider did not ensure staff always maintained accurate and complete records. The manager was unable to provide us with a clear account of the actual number of people who were in receipt of personal care.”
criticalGovernance: “The provider had not always submitted the required statutory notifications to CQC. The provider was operating from an address not registered with CQC and had not informed us of this change.”
criticalLeadership: “Changes in the management team throughout the year had a negative impact on the running of the service. Quality monitoring was not completed.”
moderateStaffing levels: “One adult was supported by nine different staff members over a twelve-day period. Their relative told us this had a negative impact on their family member.”
moderateIncident learning: “Accidents and incidents were recorded and reviewed. However, outcomes and lessons learnt were not always recorded.”
moderateCare planning: “Children's care plans were not available in a format for them to understand. The provider had no systems in place to support the children's rights. Care plans were not regularly reviewed.”
moderateCommunication with families: “Important conversations regarding people's care and support were not always recorded which led to confusion for people and relatives, which impacted negatively on the quality of care they received.”
minorPerson-centred care: “The provider did not have systems in place to gather the views of children, without the support of an adult either their relative or staff member.”
Strengths
· The provider had contingency plans in place to ensure people received continued care in the event of an emergency.
· Staff worked in partnership with external health and social care professionals to ensure people received appropriate care and support.
· Care plans for adults were person centred and provided staff with clear information on how to support people in line with their preferences.
· Children's relatives spoke positively about the caring nature of staff and the responsiveness of the service.
· During COVID-19, staff utilised their own facilities to enable people to access other surroundings and develop their independence.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentInadequate
safe: Learning lessons when things go wrongInadequate
safe: Preventing and controlling infectionInadequate
safe: Using medicines safelyRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
Good
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood
well-led: How the provider understands and acts on the duty of candourGood
effective: Supporting people to eat and drink enough to maintain a balanced diet
Insufficient evidence to rate
effective: Ensuring consent to care and treatment in line with law and guidanceInsufficient evidence to rate
caring: Ensuring people are well treated and supported; respecting equality and diversityInsufficient evidence to rate
caring: Supporting people to express their views and be involved in making decisions about their careInsufficient evidence to rate
responsive: Planning personalised care to ensure people have choice and controlInsufficient evidence to rate
responsive: Meeting people's communication needsInsufficient evidence to rate
responsive: Supporting people to follow interests and take part in activitiesInsufficient evidence to rate
responsive: Improving care quality in response to complaints or concernsInsufficient evidence to rate
well-led: Promoting a positive person-centred, open and inclusive cultureInsufficient evidence to rate
well-led: Engaging and involving people using the service, the public and staffInsufficient evidence to rate
well-led: Continuous learning and improving careInsufficient evidence to rate
well-led: Working in partnership with othersInsufficient evidence to rate
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Respecting and promoting people's privacy, dignity and independenceRequires improvement
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlRequires improvement
responsive: Meeting people's communication needsRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsInadequate
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: How the provider understands and acts on the duty of candourGood