Is the service safe? – Good
Is the service effective? – Good
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Good
KD Care is a domiciliary care agency that provides personal care and support for people living in their own homes. The agency provides ‘live-in’ carers, twenty-four hours per day, either for long term care, or for respite care. The agency office is based in Bobbing, near Sittingbourne and is easily accessible for staff and visitors. The provider has ensured that the agency office is accessible to people who may have a mobility disability. At the time of the inspection, the agency was providing support to five people. Most people were privately funded, occasionally people were funded by the local authority or through NHS continuing care services.
At the last Care Quality Commission (CQC) inspection the service was rated Good in all domains and overall.
At this inspection, we found the service remained Good.
The agency is run by the provider who is also the registered manager of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.
The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The provider and staff understood their responsibilities under the Mental Capacity Act 2005.
The agency continued to have suitable processes in place to safeguard people from different forms of abuse. Staff had been trained in safeguarding people and in the agency’s whistleblowing policy. They were confident that they could raise any matters of concern with the provider, or the local authority safeguarding team. Staff were trained in how to respond in an emergency (such as a fire, or if the person collapsed) to protect people from harm.
The agency provided sufficient numbers of staff to meet people’s needs and provided a flexible service. The agency had robust recruitment practices in place. Applicants were assessed as suitable for their job roles. Refresher training was provided at regular intervals. All staff received induction training which included essential subjects such as maintaining confidentiality, moving and handling, safeguarding adults and infection control. They worked alongside experienced staff and had their competency assessed before they were allowed to work on their own.
The provider carried out risk assessments when they visited people for the first time. Other assessments identified people’s specific health and care needs, their mental health needs, medicines management, and any equipment needed.
Incidents and accidents were recorded and checked by the provider to see what steps could be taken to prevent these from happening again. The risk in the service was assessed and the steps to be taken to minimise them were understood by staff.
The provider involved people in planning their care by assessing their needs on the first visit to the person, and then by asking people if they were happy with the care they received.
Staff had been trained to administer medicines safely. They followed an up to date medicines policy issued by the provider and they were checked against this by the provider.
People were supported with meal planning, preparation and eating and drinking. Staff supported people, by contacting the office to alert the provider to any identified health needs so that their doctor or nurse could be informed.
People said that they knew they could contact the provider at any time, and they felt confident about raising any concerns or other issues. The provider carried out spot checks to assess care staff’s work and procedures, with people’s prior agreement. This enabled people to get to know the provider.
The agency had processes in place to monitor the delivery of the service. As well as talking to the provider at spot checks, people could phone the office at any time.
People’s views were also obtained through annual surveys. These could be completed anonymously if people wished. The provider analysed these and checked how well people felt the agency was meeting their need.
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.’
This was a comprehensive inspection, which took place because we carry out comprehensive inspections of services rated Good at least once every two years. This inspection took place on 16 February 2017 and was announced. 48 hours’ notice of the inspection was given because we needed the provider to be available during the inspection. The inspection was carried out by one inspector.
Before the inspection, we looked at previous inspection reports and notifications about important events that had taken place in the home, which the provider is required to tell us by law. We used all this information to decide which areas to focus on during our inspection.
We visited the agency’s office, which was situated in the grounds of a private house. We spoke with the provider and the administrator of the agency. Following the inspection visit we spoke with one person who was supported by the agency and two relatives of people who were supported by the agency. We spoke on the telephone to three members of staff to gain their views about the agency.
We looked at the provider’s records. These included two people’s care records, which included care plans, health records, risk assessments and daily care records. We looked at a sample of audits, one recruitment record for the newest member of staff and satisfaction surveys.
We always ask the following five questions of services.
People said they felt safe receiving care from the staff at the agency. People told us they had no cause for concern regarding their safety or the manner in which they were treated by care staff. One person said, “Yes, I feel safe, I am happy with the support I get”.
Relatives said, “It is always the same carer, I am happy with the support provided”, and “The service is safe, I have no concerns”.
Staff were aware of how to protect people from abuse and the action to take if they had any suspicion of abuse. They understood the different types of abuse and how to recognise potential signs of abuse. Staff training in protecting people from abuse commenced at induction, and there was on-going refresher training for safeguarding people from abuse.
The agency’s policies and procedures were included in a staff handbook that staff could carry with them. This provided them with contact information in the event of any concerns of abuse. Staff said they would usually contact the provider or administrator immediately if abuse was suspected, but knew they could also contact the Social Services safeguarding team directly. Staff understood the whistleblowing policy. They were confident about raising any concerns with the provider or administrator, or outside agencies if this was needed. People could be confident that staff had the knowledge to recognise and report any abuse. This protected people who may require safeguarding.
The agency continued to have processes in place to protect people from abuse, for example, financial abuse. This included recording the amount of money given to care staff for shopping; providing a receipt; and recording the amount of change given. Where possible, any transaction was signed by the staff member and the person receiving support, or their representative. The provider provided people with information and prices about the services they offered. A contract was completed and agreed at this meeting and signed by both parties. This ensured that people who were paying with direct payments were fully informed and in agreement with the costs of their care. Staff were not permitted to receive gifts or be named in legacies, as a precaution against financial abuse.
Before any care package commenced, the provider carried out risk assessments of the environment, and for the care and health needs of the person concerned. Environmental risk assessments were very thorough and included risks inside and outside the person’s home. For example, approach to the house and whether the garden posed any risks. Risk assessments for inside the property highlighted if there were pets in the property and if there were any obstacles in corridors, for example, moveable radiators. Taking preventative measures reduced the number of incidents and protected people from harm.
People’s individual risk assessments included information about action to take to minimise the chance of harm occurring. For example, some people had restricted mobility and information was provided to staff about how to support them when moving around their home and transferring them in and out of their bed or to a wheelchair. One risk assessment stated, ‘Lights to be left on all the time’. People were provided with equipment to support them such as hospital type beds and pressure-relieving mattresses. Exact instructions were given about how to use individual hoists, and how to position the sling for the comfort of the person receiving support.
The provider ensured that required checks and servicing were carried out for lifting equipment. Each person had a fire action plan in place in the event of an emergency. Some people had a pendant ‘lifeline’ which could be worn around their neck. They pressed the alarm if they had an accident or were seriously unwell. These are a 24-hour care system to alert on-call operators to obtain help for people. Care staff checked that people had their lifeline pendants in place before leaving the premises.
Care staff knew how to inform the office of any accidents or incidents. They said they contacted the office and completed an incident form after dealing with the situation. The provider viewed all accident and incident forms so that they could assess if there was any action that could be taken to prevent further occurrences and to keep people safe.
Staffing levels were provided in line with the support hours agreed with the person receiving the support or in some cases with the local authority. The provider said that staffing levels were determined by the number of people using the service and their needs. Currently, there were enough staff to cover all calls and numbers are planned in accordance with people’s needs. Therefore, staffing levels could be adjusted according to the needs of people, and the number of staff supporting a person could be increased if required.
The agency continued to have robust staff recruitment practices, ensuring that staff were suitable to work with people in their own homes. These included checking prospective employees’ references, and carrying out Disclosure and Barring Service (DBS) checks before successful recruitment was confirmed. DBS checks identify if prospective staff have had a criminal record or have been barred from working with children or vulnerable people. Employment procedures were carried out in accordance with equal opportunities. Interview records were maintained and showed the process was thorough, and applicants were provided with a job description. Successful applicants were provided with the terms and conditions of employment, and a copy of key policies, such as maintaining confidentiality, emergency procedures and safeguarding. New staff were required to complete an induction programme during their probation period so that they understood their role and were trained to care for people safely.
Staff were trained to assist people with their medicines where this was needed. Checks were carried out to ensure that medicines were stored appropriately, and care staff signed medicines administration records for any item when they assisted people. Records had been accurately completed. Staff were informed about action to take if people refused to take their medicines, or if there were any errors. The provider checked that the staff continued to follow safe administration practices as stated in the provider’s policy.
People said that they thought the staff were well-trained and attentive to their needs. Feedback from people was very positive, and relative’s comments included, “My relative has been able to remain in her own home with support from good staff”, “They ensure the staff provided have the relevant experience to meet her needs and work on the best match personality-wise as well”. People’s needs were assessed, recorded and communicated to staff effectively. The staff followed specific instructions to meet individual needs.
Staff continued to have appropriate training and experience to support people with their individual needs. Staff completed an induction course, and a staff member told us about completing the 15 modules of the Care Certificate. These are the standards that people working in adult social care need to meet before they can safely work and provide support for people. The induction and refresher training included all essential training, such as moving and handling, fire safety, safeguarding, first aid, infection control and applying the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Staff were given other relevant training, such as understanding dementia, principles of person-centred care and effective communication. It helped to ensure that all staff were working to the expected standards and caring for people effectively, and for staff to understand their roles and responsibilities.
Staff were supported through individual supervision and the provider carried out yearly appraisals for all staff. Spot checks of staff were carried out in people’s homes. A spot check is an observation of staff performance carried out at random. These were discussed with people receiving support at the commencement of their care package. At this time people expressed their agreement to occasional spot checks being carried while they were receiving care and support. People thought it was good to see that the staff had regular checks, as this gave them confidence that staff were doing things properly. Staff told us that the provider would occasionally arrive unannounced to carry out a spot check. This included personal appearance of staff, politeness and consideration, respect for the person and the member of staffs’ knowledge and skills. Spot checks were recorded and discussed, so that staff could learn from any mistakes, and receive encouragement and feedback about their work.
Staff were trained in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Staff understood the processes to follow if they felt a person’s normal freedoms and rights were being significantly restricted. The provider is a trained trainer in MCA and DoLS and carries out a mental capacity assessment at the first visit, to determine people’s ability to understand their care needs and to consent to their support. When people lacked mental capacity or the ability to sign agreements, a family member or representative signed on their behalf. The provider met with family members and health and social care professionals to discuss any situations where complex decisions were required for people who lacked capacity so that a decision could be taken together in their best interests. For example, getting specialist equipment for a person whose mobility had deteriorated.
Staff sought and obtained people’s consent before they helped them. One person told us “They always ask me what I want doing”. Staff checked with people whether they had changed their mind and respected their wishes. Staff were matched to the people they were supporting as far as possible, so that they could relate well to each other. The provider introduced staff to people, and explained how many staff were allocated to them. People got to know the same staff who would be supporting them. This allowed for consistency of staffing, and cover from staff that people knew in the event of staff leave or sickness.
When staff prepared meals for people, they consulted people’s care plans and were aware of people’s allergies, preferences and likes and dislikes. People were involved in decisions about what to eat and drink as staff offered options. The people we spoke with confirmed that staff ensured they had sufficient amount to eat and drink. Having enough to eat and drink protected people from the risk of dehydration and malnutrition.
People were involved in the regular monitoring of their health. Staff identified any concerns about people’s health to the provider, who then contacted their GP, community nurse, mental health team or other health professionals. Each person had a record of their medical history in their care plan, and details of their health needs. Records showed that the staff worked closely with health professionals such as district nurses in regards to people’s health needs. This included applying skin creams, recognising breathing difficulties, pain relief, catheter care and mental health concerns. Occupational therapists and physiotherapists were contacted if there were concerns about the type of equipment in use, or if people needed a change of equipment due to changes in their mobility. This promoted people’s access to health care to maintain their wellbeing.
One person said, “It is comforting to have the same staff, they know me really well now”. Relatives told us, “The staff are caring”, “We know the carers well, the staff are dedicated and caring”.
Positive caring relationships were developed with people. Staff told us they valued the people they visited and spent time talking with them while they provided care and support. Staff were made aware of people’s likes and dislikes to ensure the support they provided was informed by people’s preferences. People told us they were involved in making decisions about their care and staff took account of their individual needs and preferences. Regular reviews were carried out by the provider and any changes were recorded as appropriate. This was to make sure that the care staff were fully informed to enable them to meet the needs of the person.
People had been given a service guide by the provider. This included the objectives of the service, how to make complaints, what the service provided, and the ‘principles’ of the agency. ‘We aim to provide all out clients with care and support that has a positive impact on their lives’. This described the kind of service the provider wanted people to experience. People could refer to this information at any time if they wanted to.
The agency had reliable procedures in place to keep people informed of any changes. The provider told us that communication with people and their relatives, staff, health and social care professionals was a key for them in providing good care. People were informed if their regular carer was off sick, and which care staff would replace them. The provider would cover, if there was no other staff member available at the time.
People were informed of agency processes during the assessment visit. The provider provided people with information about the services of the agency. They told people they could contact the agency at any time; there was always a person on call out of hours to deal with any issues of concern. One person commented, “I have always been able to contact someone when I have needed support, they provide an excellentservice”.
Staff confirmed that they liked to know as much as possible about the people they were caring for and relatives were able to provide information too, letting them know of any preferences people might have. Staff took account of the way people liked to communicate. This could include body language or behaviours that indicted people were distressed or in pain. This meant people received the care they wanted.
Staff told us they always asked for people’s consent before carrying out personal care tasks or offering support. They said that if people declined their support that this was people’s right and they respected their decision. Staff acted on people’s responses and respected people’s wishes if they declined support.
Staff had received training in equality and diversity, and treated everyone with respect. They involved people in discussion about what they wanted to do and gave people time to think and made decisions. Staff knew about people’s past histories, their life stories, their preferences and the things they liked and disliked. This enabled them to get to know people and help them more effectively. Staff ensured people’s privacy whilst they supported them with personal care, but ensured they were nearby to maintain the person’s safety, for example if they were at risk of falls. One relative commented, “I am happy with the support provided. Mum is treated with dignity and respect and maintains as normal a routine as possible”. Staff were respectful of people’s privacy and maintained their dignity.
People described staff as being ‘adaptable’ and ‘meeting their needs’. Relatives told us, “They always respond quickly, and I can always contact them”, and “The provider and administrator are always available to Mum, us as relatives and their staff. This means when anything happens, or if we are unsure of anything they are there to guide, comfort or support us. There is never an answer machine asking to us to leave a message or wait until the next day or over the weekend”.
The provider carried out people’s needs and risk assessments before the care began. They discussed the length of the ‘live in’ visits that people required, and this was recorded in their care plans. Clear details were in place for exactly what staff should carry out whilst they were ‘living in’. This might include care tasks such as washing and dressing, helping people to shower, preparing breakfast or lunch, giving drinks, turning people in bed or assisting with medicines. The domestic tasks may also be included such as doing the shopping, changing bed linen, putting laundry in the washing machine and cleaning. The staff knew each person well enough to respond appropriately to their needs in a way they preferred and support was consistent with their plan of care.
Staff were informed about the people they supported as the care plans contained information about their backgrounds, family life, previous occupation, preferences, hobbies and interests. The plans included details of people’s religious and cultural needs. The provider matched staff to people after considering the staff’s skills and experience. Care plans detailed if one or two care staff were allocated to the person, and itemised each task in order, with people’s exact requirements. This was particularly helpful for care staff assisting new people, or for care staff covering for others while on leave, when they knew the person less well than other people they supported, although they had been introduced.
The provider carried out care reviews with people and was regularly in touch with them to make sure people’s needs were being met. Any changes were agreed together, and the care plans were updated to reflect the changes. Staff who provided care for the person were informed immediately of any changes. Care plans were also reviewed and amended if staff raised concerns about people’s care needs, such as changes in their mobility, or in their health needs. The concerns were forwarded to the appropriate health professionals for re-assessment, so that care plans always reflected the care that people required. This protected people from receiving inappropriate care not based on their most up to date needs.
The agency’s questionnaire responses from 2016 supported what people told us. People had been asked to confirm their views about the service by answering questions. Questions included, ‘Did you find KD Care provided a suitable carer for you or your family member’; ‘Did the carers of KD Care act professionally and respectfully towards you’ and ‘Did the carers of KD Care respect you wishes and dignity’. All responses were positive and people rated the service as excellent. People had commented, ‘Absolutely first rate care, could not recommend them more highly in every aspect of care. Fantastic’, ‘Everything excellent’, ‘The best care I have had, they are very supportive and always there to answer my questions and give support’, and ‘As Mum’s awareness faded in an out they remained patient and caring and were always there for her. When Mum needed 24 hour care, the carers devised a routine to double up to cover Mum’s needs, avoiding the Good need to introduce new people to Mum which would have disconcerted her. I cannot praise the carers or the company themselves enough’.
People were given a copy of the agency’s complaints procedure, which was included in the service users’ guide. People told us they would have no hesitation in contacting the provider or administrator if they had any concerns, or would speak to their care staff. The provider dealt with any issues as soon as possible, so that people felt secure in knowing they were listened to, and action was taken in response to their concerns. The provider visited people in their homes to discuss any issues that they could not easily deal with by phone. They said face to face contact with people was really important to obtain the full details of their concerns.
The complaints procedure stated that people would receive an acknowledgement of their complaint within two days, and the agency would seek to investigate and resolve the complaint within 28 days. The provider said that any concerns or complaints were regarded as an opportunity to learn and improve the service, and would always be taken seriously and followed up. People told us they knew how to raise any concerns and were confident that the provider dealt with them appropriately within a set timescale.
People spoke highly of the provider and administrator and said that staff listened to them. Written compliments received from relatives included, ‘I shall never forget how you and your team so wonderfully stepped in when I was desperate for care for Mother and the kindness staff showed to my Mother’, ‘I shall never forget the help you all gave me and my dear Mother when we were so desperate’, and ‘Thank you so much for coming to our rescue when she came out of hospital and for all your support and advice at such a difficult time. Mother and I very much appreciated all you did for us. You may be a small team but I like your style’.
Staff survey comments included, ‘The best company I have worked for. If I have an issue either with a client or other staff they are always around to help resolve the situation’, ‘Very pleased to be employed by them. Love the personal contact and prompt payment’, and ‘I have found the management to be extremely supportive to clients and their families and of course the carers. Their overall conduct is very professional and I would be happy to work for/with them always’.
Our discussions with people, their relatives, the provider, administrator and staff showed us that there was an open and positive culture that focused on people. The agency had a culture of fairness and openness, and staff were listened to and encouraged to share their ideas.
Organisational values were discussed with staff, and reviewed to see that they remained the same. Staff felt that they had input into how the agency was running, and expressed their confidence in the leadership. One member of staff commented, “Good agency to work for”, and “Company really with you in the job, check you are okay and everything is okay”. The provider and administrator both worked directly with people receiving support. They said that this enabled them to keep up to date with how people were progressing. Staff said it gave them confidence to see that the management had the skills and knowledge to deliver care and support, and it was helpful to work alongside them from time to time.
The management team included the provider and the administrator. The provider was familiar with her responsibilities and conditions of registration as she had attended a workshop that covered the new regulations and their impact on services. The provider kept CQC informed of formal notifications and other changes. The provider had managed the agency for a number of years and had concentrated on consolidating existing processes and bringing about a number of changes. They had set targets for staff supervisions, spot checks, risk assessments and care reviews, and this work was on-going. It was clear that the provider and administrator complemented each other’s skills and worked together for the good of the agency. They showed a passion to ensure that people were looked after to the best of their ability
People were invited to share their views about the service through quality assurance processes, which included regular phone calls or visits from the provider; care reviews with the provider; yearly questionnaires; and spot checks for the care staff who supported them. This process was agreed when the provider and carried out the first visit, and people were pleased to know that someone would be coming in to check that care staff carried out their job correctly. The provider conducted spot checks and these monitored staff behaviours and ensured they displayed the values of the agency. This had the added benefit of enabling people to get to know the provider, as well as their usual care staff. The management team ensured the values and behaviours were maintained through these regular spot checks.
There continued to be systems in place to monitor the quality of the service provision which meant that the service was able to assess and any concerns were addressed promptly. The ethos of providing good care was reflected in the record keeping. Clear and accurate records were maintained, and comprehensive details about each person’s care and their individual needs. Care plans were reviewed and audited by the provider on a regular basis.
Policies and procedures continued to be updated to make sure they reflected current research and guidance. Policies and procedures were available for staff. The provider’s system ensured that the staff were aware of procedures to follow and of the standards of work expected of them to provide safe, effective, responsive care and support for people.