The inspection took place on 11 and 23 March 2016. The inspection was announced.

Angel Heart Home Care Limited is a domiciliary care agency providing care to people living in their own homes. Since the last inspection of the service in September 2015 the local authority stopped commissioning services with Angel Heart Homecare Limited. This meant that the number of people receiving care has reduced significantly. At the time of this inspection the service provided care to eight people, seven of whom lived with relatives or carers.

At our inspection on 2 April 2015, breaches of legal requirements were found and we took enforcement action against the provider. We issued warning notices in relation to person centred care and good governance. Requirement actions were served in relation to staffing and safe care and treatment. The provider wrote to us to say what they would do to meet legal requirements in relation to safe care and treatment, person centred care, good governance and staffing.

We undertook a further inspection on 29 September 2015 and 2 October 2015 to check that they had followed their plan and to confirm that they were meeting legal requirements. We found the provider had made some of improvements however sufficient improvements had not been made to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) 2014. Some of these breaches were repeated because the provider had failed to take proper action. As a result of this we put Angel Heart Home Care Ltd in Special Measures.

This comprehensive inspection was conducted to check that the actions taken by the provider meant they were now meeting their legal requirements. We found that the provider had made improvements in some areas which had made a positive difference to people they support. The improvements made meant the overall rating is now Requires Improvement and we have taken Angel Heart Home Care Ltd out of Special Measures.

However, we found the provider continued to breach a number of requirements of the Health and Social Care Act 2008 (Regulated Activities) 2014.

The provider was also the registered manager for 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 provider did not always operate safe recruitment practices. Risk assessments for staff with past convictions were not always completed and reference checks were not satisfactory.

Risks to people’s safety and well-being were not always adequately assessed and guidance for staff was not always provided. The service did not support anyone who required assistance with oral medication. Where topical creams were prescribed there was insufficient guidance for staff to follow in how and where to apply the creams.

Information relating to people’s care was not always recorded in an accessible manner. Although actions were taken to address changing needs these were recorded in a number of different places which meant that care staff did not always have the most up to date information.

The service had electronic monitoring systems in place to reduce the risk of people’s care calls being missed and feedback from people was they had not experienced any missed calls since our last inspection. People’s rights were protected and they were safeguarded from the risk of abuse because staff understood their roles and responsibilities in protecting them.

Improvements had been made in the monitoring of staff training. However, one staff member had not completed all of the appropriate training to support them in their role. Staff received regular supervision and spot checks were completed to monitor the quality of their work. Where issues with staff performance were identified these w

We inspected Angel Heart Home Care on the 2 April 2015 and it was an announced inspection.

The overall rating for Angel Heart Home Care is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action

Angel Heart Home Care is a domiciliary care agency providing personal care for a range of people living in their own homes. These included people living with dementia, older people and people with a physical disability. The support hours varied from one to four calls per day, with some people requiring two members of care staff at each care call. The agency’s office was based in Camberley and the agency offered support and care to people in Camberley, Frimley, Blackwater and the surrounding area. At the time of our inspection, the agency was supporting up to 18 people and employed four members of staff.

The owner (provider) of Angel Heart Home Care was also the registered manager. A registered manager is 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.

People spoke highly of the care staff and felt they were kind and caring. However, people commented there had been significant issues with the time-keeping of care staff; not being aware of when their next care call would be or experiencing missed calls. One person told us, “Not sure how things are going to be from one day to the next.”

Staffing levels were stretched. The provider had experienced high level of staff turnover in a short period of time. On the day of the inspection, the provider only had three care staff working and themselves to cover the care calls. People and their relatives reflected that staff shortages meant the care staff were often rushed or commenting on how busy they were. One relative told us, “They’re very quick; they want to get the job done. They need to slow down.”

Recruitment practice was not consistently robust and mechanisms were not in place to assess care staff’s competency with medicine administration or moving and handling. The provider had not been providing carers with formal supervision and systems were not in place to assess whether training was embedded into practice.

Where people were prescribed topical creams, daily recordings not did consistently reflect when or if the prescribed cream was administered.

People told us care staff always gained their consent before providing personal care; however, care staff had not received training on the Mental Capacity Act 2005 (MCA) and were unaware of their legal responsibilities under the legislation.

Risk assessments were not consistently completed and did not reflect the actions required to minimise the risk of any potential harm. Care plans lacked information on the person’s preferences, life history or how they wished to receive their care and support. Mechanisms were not in place for the formal reviewing of people’s packages of care to ensure that staff had up to date guidance on changes in people needs.

The provider had not ensured there were effective systems in place to monitor and improve the quality of the service provided. Therefore they were not meeting the requirements to protect people from the risk and unsafe care by effectively assessing and monitoring the service being provided.

People confirmed care staff respected their privacy and dignity. Care staff had a firm understanding of respecting people within their own home and leaving people’s property secure at the end of a care call.

Care staff commented they felt valued as employee’s but also recognised the impact of the staff shortages and the challenges they had been facing. One carer told us, “It’s been a hard month, covering all the care calls.”

People and their relatives felt the recent shortfalls within the service were associated with staff shortages rather than neglect on the part of the care staff or the agency. One person told us, “Have some really nice, excellent care but the last month have not felt so secure.”

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

On the day of the site visit the agency provided care and support to one person who was supported by one carer who was the registered manager.

One person told us they were happy with the care and support they received from the agency. One person said, “The registered manager consulted with me, and I signed the care plans to show I agree to the care and support in the plans”.

One person told us the manager made regular contact with them and asked on each visit if they were happy with the care they were provided.

One person told us what they liked best about the agency was the way the registered manager involved them in their care. One person said, “The registered manager discusses my care with me. I know what is going on. Nothing is hidden from me”.

The person whom we spoke with told us they had never had to make a complaint. We observed the service had a complaints log in place. We observed their complaints guidelines were included in the person's personal care file which was kept by the person.

We found that the person’s risk assessments were carried out and action plans were in place to minimise or reduce the identified risks.

We inspected Angel Heart Home Care on the 29 September and 2 October 2015 and it was an announced inspection.

At our last inspection on 2 April 2015, breaches of legal requirements were found and we took enforcement action against the provider. We issued warning notices in relation to person centred care and good governance. Requirement actions were served in relation to staffing and safe care and treatment. The provider wrote to us to say what they would do to meet legal requirements in relation to safe care and treatment, person centred care, good governance and staffing.

We undertook this comprehensive inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found the provider had made pockets of improvements however, sufficient improvements had not been made to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) 2014. Some of these breaches were repeated because the provider had failed to take proper action after the last inspection.

The overall rating for Angel Heart Home Care is ‘Inadequate’ and the service therefore remains in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Angel Heart Home Care is a domiciliary care agency providing personal care for a range of people living in their own homes. These included people living with dementia, older people and people with a physical disability. The support hours varied from one to four calls per day, with some people requiring two members of care workers at each care call. The agency’s office was based in

Camberley and the agency offered support and care to people in Camberley, Frimley, Blackwater and the surrounding area. At the time of our inspection, the agency was supporting up to 17 people and employed six care workers.

People and their relatives felt there had been improvements with the running of the agency in the past two weeks. One person told us, “My care has been better these past two weeks after the office staff have been out doing the work.” One relative told us, “They seem to have some new care workers and trying to improve over past two weeks but am exhausted chasing things up.” Although people felt some improvements had been made, the provider had not fully addressed the issues we found at our last inspection.

Risks to people’s safety continued to be poorly managed. Risk assessments lacked sufficient guidance and information to enable care workers to provide safe care. Moving and handling risk assessments failed to document specific information required to safely move and transfer people. Where restrictive practice was used, robust risk assessments were not in place and did not provide detailed information about reducing the risks or what was in people’s best interest.

Care plans lacked detailed information on how to effectively meet people’s nutritional needs. For people who required a soft or puree diet, guidance was not in place on how to minimise any potential risks of choking. Where people required support to maintain a healthy diet or support with dietary requirements, such as diabetes, guidance and information was not in place.

The provider had not followed best practice guidance when they had recruited new care workers. New care workers had not been fully vetted before they worked with people.

The provider had not been able to respond fully to the inadequacies we raised with them at our last inspection. They had a lack of understanding about prioritising people’s safety which was demonstrated by the continued lack of proper risks management, medicines management and safe staff recruitment practices. Audits were being carried out by the management team but they had failed to understand how they needed to follow relevant legislation and best practice. The provider was unaware of their legal requirement to display their Care Quality Commission (CQC) rating. Incidents and accidents were not monitored for any emerging trends, themes or patterns.

People and their relatives raised concerns over the timekeeping of care workers, not being informed if the care worker was running late and calls times being inflexible and not personalised to them. One person told us, “We never know who is coming sometimes no one comes and sometimes have duplicated calls.” Relatives also raised concerns regarding poor management of complaints. One relative told us, “They are not diplomatic when we raise concerns.”

A database management system was now in place which provided a centralised system of recording everyone’s details and frequency of care calls. The provider had also implemented a telephone monitoring system whereby care workers logged in and out care calls. This provided a clear audit trial of when care workers were late to a care call and provided a system for monitoring for any missed calls.

The provider had taken action to ensure care workers received the training and support required to effectively undertake their job role. Care workers now received regular supervision, team meetings were taking place. Face to face training was implemented and spot checks were being undertaken. Mechanisms were now in place to assess care worker’s competency with the training provided and ensure it is embedded into practice.

Care workers spoke with compassion for the people they supported. Individual reviews had been taking place which considered what was working for people and what was not working. However, further work was required to ensure care plans and risk assessments were updated following any review. Work was still being undertaken to ensure care plans were personalised.

Overall, we found shortfalls in the care provided to people. We identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. We will publish what action we have taken at a later date.