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Care and Social Services Inspectorate Wales
Care Standards Act 2000
Inspection Report
St Helens
Unit 3
Hatherleigh Place
Union Road
Abergavenny
NP7 7RL
Type of Inspection – Baseline
Date of inspection – Friday, 09 January 2015
Date of publication – Thursday, 19 March 2015
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Summary
About the service
St Helens Domiciliary Care Agency has been registered with Care and Social Services
Inspectorate Wales (CSSIW) since 2005 and is registered to provide personal care to
older people, people with learning and/or physical disabilities and people with mental
health problems. It currently operates four small supported living schemes as well as some
spot contracts. It is registered to provide care services within Monmouthshire, Torfaen and
Blaenau Gwent. The agency office is situated on an industrial park in Abergavenny, on
the first floor of a two storey building. There is no disabled access to the office space.
There are two directors for the company. At the time of the inspection there was no
registered manager in post and there has not been one for the past 18 months. This is in
breach of the Care Standards Act 2000.
What type of inspection was carried out?
An announced, baseline inspection which examined Quality of life, quality of staffing and
quality of leadership and management was undertaken on Friday 9 January 2015. It was
an announced inspection as inspectors had to arrange to meet with service users and to
also gain access to records and management systems held at the office. The following
methodology was used to gather evidence for this report:
discussions with three service users
discussions with managers and care staff
one completed staff questionnaire
analysis of information held at service users’ homes such as daily records, service
delivery plans and risk assessments
inspection of three staff personnel files
analysis of records relating to management of the organisation such as staff training
matrix, weekly and monthly audits completed by managers
consideration of a range of operational policies such as Finance, Complaints,
Statement of Purpose and annual Quality of Care report.
What does the service do well?
The organisation’s policies and procedures help to create a culture of respect and
dignity in the care and support they provide to the users of the service.
There is a robust quality assurance process in place, which demonstrated that
management have listened and responded to feedback by staff and service users
alike, as part of this process.
What has improved since the last inspection?
There was evidence that internal care plan reviews have taken place in a timely
manner
Documents within care files were seen to be dated and placed in chronological
order
Agency staff no longer act as appointees for service users
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What needs to be done to improve the service?
We informed the agency’s management team that the service was non-compliant with the
following Domiciliary Care Agencies ( Wales) Regulations 2004:
Regulation 16(1)(a) This is because the registered provider had failed to ensure
that at all times an appropriate number of suitably qualified, skilled and experienced
persons are employed. This relates specifically to a number of staff not having
undertaken suitable refresher training in First Aid and POVA (Protection of
Vulnerable Adults)
Regulation 9(1)(a) This is because the registered provider has failed to recruit a
suitably qualified and experienced person to act as a Registered manager for the
past 18 months
We (CSSIW) have not issued a non-compliance notice in respect of these matters on this
occasion. The agency’s managers are aware their responsibility to rectify the matters
identified and CSSIW anticipates that all necessary action will be taken and specifically
that a registered manager will be appointed and be in post by 30 th September 2015, if this
deadline is not met, a non compliance notice will then be issued
The following recommendations were also made:
ensure that formalised staff team meetings are undertaken with increased
frequency of at least once every three months.
review recording of information and ensure that there are consistent
practises of recording and maintaining information relating to people’s care
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Quality Of Life
Overall we (CSSIW) found that service users are supported to live as independently as
possible, in line with their needs identified in their care plans.
People are treated with dignity and respect. This is because we spoke with three service
users who informed us that this was the case. We saw mutually warm and respectful
exchanges from staff interactions with the people they supported. There was an element
of friendly and appropriate banter and service users were clearly comfortable in their
surroundings and with the staff who were supporting them. We noted that the
organisation’s policies and procedures helped to create a culture of respect and
dignity in care and this was underpinned in their induction programme for staff and on
going training and support. All people we spoke with stated they were happy with the
care they received and enjoyed living in their homes.
People are suitably active, positively occupied and stimulated with appropriate
consideration given to their age and health needs. We saw from plans and daily records
that people were supported to access community facilities and for some, day
opportunities such as Office Services. Meadow Mill Crafts also visited people in their own
homes on a weekly basis to make leather goods like purses and bags. People were
encouraged to participate in a range of household chores as well as undertake their
weekly shopping. These opportunities ensure that people maintain and/or increased
their independent living skills as well as enjoying social interactions and leisure activities.
People experience appropriate care from a responsive staff team, who have an up to
date knowledge of their care needs. This is because many of the staff had worked for
the agency for some time and knew the users of the service well. We saw from the
service delivery plans that these were very well detailed, with appropriate risk
assessments in place. The information contained in the plans was person centred and
gave clear advice and guidance to support staff. All plans examined had been reviewed
within the past 12 months. However, we did note in one file that information relating
specifically to a person’s weight was “haphazard” and information was held in different
places. There was a lack of consistency in recording information throughout the file. We
spoke to the management team about this and they agreed that the information should
be stored in the same place and gave assurances that they would address this as a
priority.
People experience warmth, attachment and belonging as we saw that people’s
bedrooms were personally furnished with their belongings such as TV as well as an array
of photographs and personal mementoes. In one setting we saw that they had a pet dog
which they cared for with support from the staff team. We noted that the homes we
visited were well maintained and furnished to a good standard. People we spoke with
were proud of their homes and enjoyed looking after it and investing their time in its
upkeep. In most cases they considered it a “home for life” and had a strong sense of
belonging.
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Quality Of Staffing
Overall, we found that staff were keen to provide a quality service and were
knowledgeable regarding the needs of the people they supported.
People can feel confident in the care they received because staff were generally well
trained in a range of competencies. In our discussions with staff, they told us that they
were confident in meeting the needs of the people they supported. We examined three
staff files and noted that there was a thorough and well detailed induction programme for
new staff. Additionally staff undertook statutory training such as First Aid, Manual
Handling and POVA (Protection of Vulnerable Adults) as well as completing induction
care shifts with more experienced members of staff. This approach meant that new staff
had the necessary skills and knowledge to undertake their work with some confidence.
We noted that there was an On Call system that was available 24 hours per day and staff
stated in conversations with us that this provided them with an increased sense of
security. However, on closer inspection of the staff training matrix we saw that for some
staff, refresher training in areas such as POVA and First Aid was overdue. We spoke
with the managers of the service and they were able to show us that they had booked
some staff onto the relevant training courses and agreed that as a matter of priority they
would ensure all relevant staff would undertake the appropriate training as soon as
possible, in accordance with Regulation 16 (1)(a). We received written information
following the inspection that many staff had been booked onto the appropriate training
over the coming months.
People are cared for by staff that were familiar to them as turnover was low and we were
informed that agency staff were not used. Care staff we spoke with told us that they had
been with the organisation for some years. We saw from staff rotas that each supported
living setting had a regular team of staff who worked with them. However, all staff were
inducted across the four schemes and this provided increased flexibility when
management needed to cover staff sickness, annual leave or training. Part time staff also
undertook additional shifts and this approach ensured there was continuity of staff and
care provision for the service users.
People have timely care and support as staff rotas are based on the current needs and
service delivery plans of the people they support. We were told by managers that staff
were extremely flexible and would often alter their working patterns to accommodate the
needs and wishes of the service users. This meant that plans for social outings or
medical appointments were accommodated.
People tell us that they enjoy being with care staff and therefore experience an
enhanced well being from their interactions with staff. We saw from individual plans,
daily records and medical reports that staff supported people with a full range of social,
physical and medical interventions. Service users told us that “I like living here, staff are
kind to me and I can do what I want.” Another person told us “staff are lovely to me, they
treat me well.”
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Quality Of Leadership and Management
Overall, we found that St Helens Domiciliary Care Ltd is managed by a competent
team of managers who hold the welfare and positive wellbeing of the people they
support at the centre of the service. However, the registered provider has failed to recruit
a suitably qualified and experienced person to act as a registered manager for the past
18 months and therefore are not compliant with Regulation 9(1)(a).
People using the service, working in the service or linked to the service are clear about
what it sets out to provide. There is a comprehensive Statement of Purpose which
clearly informed people of the services the agency can provide and its’ underlying
principles and philosophy on providing care to people. This was last reviewed and
updated in November 2014. We also viewed a sample of working policies and
procedures, these were also seen to be generally well written and detailed in content.
People using the service are involved in defining and measuring the quality of service.
This is because the agency undertook an annual quality assurance review; the report
was circulated in December 2014. As part of the process they considered the views of
relevant stakeholders such as service users, parents and guardians, other professionals
and care staff. The review highlighted areas of improvement made since the previous
review and report. The report was comprehensive and well detailed. It included action
points that the management team had implemented in order to address concerns raised
in the questionnaires; Employee of the Month was an example of this. Actions for 2015
were detailed in the report and these were seen to be clear and measureable. Therefore,
people can be assured that the service strives to make improvements for those whom
they support and the people who work for the agency.
People can be assured that if they are not happy with the service, their concerns will be
addressed quickly. On examination of the Complaints Policy, associated records and
staff personnel files we saw that concerns were taken seriously and responded to in a
timely and robust fashion. We saw that there was a clear audit trail and outcomes were
recorded and people informed of those outcomes. The Complaints Policy had been
updated to include the revised way in which CSIW responds to complaints.
People can be confident they are safe as the business is well run and in accordance with
the Domiciliary Care Agencies (Wales) Regulations 2004 and the National Minimum
Standards for Domiciliary Care Agencies in Wales (2004). On examination of staff files
we saw that the necessary security checks such as Disclosure and Barring Service
(DBS) were in place. Staff files checked showed that two references had been sought
for care staff. We also saw that supervision took place within the required timescale of
every three months and staff had an annual appraisal. Their personnel files contained the
relevant information as outlined in Schedule 3 of the regulations. However, we were not
able to find evidence of regular team meetings. Following the inspection we were sent a
copy of a staff team meeting minutes from December 2014. Staff meetings should be
held at least every three months.
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Quality Of The Environment
Quality of environment is not considered as part of the Domiciliary Agency inspection
process undertaken by CSSIW.
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How we inspect and report on services
We conduct two types of inspection; baseline and focussed. 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. Focussed
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.
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