The inspection took place on 1 March 2017 and was announced.

Better Healthcare Services (Norwich) provides a domiciliary care service to people living in their own homes. At the time of the inspection they were providing a service to four people.

There was a manager in post who, at the time of this inspection, had applied to be registered with the Care Quality Commission. Their application was being processed. 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.

We inspected this service in February 2016 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Six breaches of legal requirements were found and the provider was required to send us a plan to tell us about the actions they were going to take to meet these breaches. This was received in the specified time.

A further inspection was carried out in August 2016 where we found that sufficient improvements had not been made and the service was in breach of five regulations, four of which were repeated breaches. We served a notice of decision to impose conditions on the service’s registration. This meant they were unable to take on any new packages of care or extend any existing ones. This action was implemented in order to help drive improvement in the quality of the service. Following this inspection in August 2016, the service also lost its contract with the local authority to provide care and support to people in Norfolk.

This service was also placed in Special Measures following the inspection in August 2016. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

During this inspection, carried out in March 2017, the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Shortly before this inspection, the service had applied for the conditions that had been imposed following our inspection in August 2016, to be removed. Following this planned inspection, the application was processed and due to the sustained improvements seen, the imposed conditions were removed.

The service had implemented a number of quality monitoring systems following the inspection in August 2016. These had driven improvement following close assessment and monitoring of the service delivery. Action plans had also been employed and systematically completed. Care records, staff’s ability to perform their role and the quality of the service had all been regularly monitored and analysed.

People told us that the service had improved. People had continuity of care and saw the same group of staff. Staff turned up at the agreed time and stayed for the approved amount of time. Both the people who used the service, and staff, received rosters in good time so they knew planned arrangements in advance.

People received care and support that was individual to them and tailored to meet their personal preferences, needs and routines. The service took into account people’s choices, life histories and personalities when designing care plans. Care plans were person centred and people’s needs had been regularly reviewed.

Staff demonstrated a courteous, warm and respectful approach when supporting people. People’s dignity was maintained and staff understood the importance of encouraging and promoting people’s independence. People spoke of a service that was professional and caring.

Complaints had been thoroughly recorded, investigated and answered. The service used them to further

The inspection took place on 25 August 2016 and was announced.

Better Healthcare Services (Norwich) provides a domiciliary care service to people living in their own homes. At the time of our inspection they were providing a service to 104 people living in the Norwich and North Norfolk areas

At the time of the inspection, the service did not have a registered manager in post. 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. However, a manager had been appointed and had started four days prior to our visit. The service’s registered manager had left in June 2016 and the operations manager had been overseeing the service in the interim.

We last inspected this service on 17 February 2016 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of six regulations relating to person-centred care, need for consent, safe care and treatment, receiving and acting on complaints, staffing and good governance. Following the inspection in February 2016, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations.

At this inspection in August 2016, we found four continued breaches, and one new breach, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to person-centred care, dignity and respect, receiving and acting on complaints, staffing and good governance. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

The provider had failed to have effective systems in place to improve the quality of the service. No processes were in place to assess and monitor the service and the negative impact this was having on people. Where people had raised complaints or concerns about the service they received, these had not always been recorded, investigated or addressed.

People’s needs were not consistently being met due to unavailability of staff and disorganised management and administration of the service. People had experienced a number of missed, late or cancelled calls and this had, in some instances, had a negative impact on their physical or emotional wellbeing. People did not consistently receive a roster so were unaware of who would be assisting them or whether the call had been covered. This caused people considerable anxiety.

The service had caused distress to some of the people whose preferences they had not met. People were receiving assistance with their personal care from male carers when they had requested female only ones. The times the service agreed they would provide care and support were not always met, with some calls being over an hour late. People’s dignity was not always maintained as result.

There were not enough suitably trained staff to meet people’s needs. Some staff had not received training as specified by the provider nor an appraisal. No spot checks had been completed to ensure staff were competent in their role although some had received this in relation to medicines administration. Staff had not received regular supervision.

The communication skills of the office staff was poor. People told us that they didn’t receive correspondence from the office and were not kept informed of changes to the service in general or to the personal service they received. Staff also experienced poor communication in regards to their role and what was expected of them. They often received their rotas late or, if the

The inspection took place on 17 February 2016 and we contacted the service before we visited to announce the inspection.

Better Healthcare Services (Norwich) provides domiciliary care to approximately 95 people living in their own homes, some of whom may be living with dementia or long term health conditions. The service procured a block contract from Norfolk County Council to deliver services to people in North Norfolk in November 2015. They are currently working in close partnership with Norfolk County Council to address issues highlighted in this report and to ensure service provision is maintained at an appropriate level.

At the time of our inspection there was a registered manager in post. 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.

Although there were gaps in training, staff demonstrated the skills and knowledge to support people and meet their needs. However, their competency in their role had not been regularly assessed by the service. Staff had been safely employed following appropriate recruitment checks. Although regular supervisions had not taken place, staff felt supported by the registered manager and office staff. They demonstrated a commitment to the people they supported.

There were not enough staff to meet people’s needs. The service had experienced a number of missed or late calls and this had had an impact on the service people received. A recruitment officer had been employed to assist the recruitment of staff and the service had a contingency plan in place. However, due to staff shortages and sickness the contingency plan had not been effective.

Staff demonstrated they understood the different types of abuse and knew how to report any concerns they may have. However, the service had not consistently reported safeguarding concerns to the local safeguarding team or the Care Quality Commission (CQC). The service had failed to consistently identify, assess and manage the risks associated with the people they supported and their staff.

Staff knew how to safely administer people’s medicines. However, medicines were not safely managed because the associated records were inconsistent and did not always give a clear picture of what medicines had been administered and when. The service also did not consistently audit medicines administration in order to identify any issues and rectify concerns.

The service had been experiencing issues since the procurement of a contract in November 2015. As a result, the service had received a number of complaints. The service had not always addressed these promptly and some of the complainants were dissatisfied with how their complaints had been managed. The staff and people we spoke with who used the service had mixed feelings on how the service was addressing recent concerns. Most staff had confidence in the service although not all people who used the service agreed.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 and report on what we find. Staff had variable knowledge of the MCA and some told us they had not received training in this. The service did not adhere to the principles of the MCA and people’s human rights were compromised. However, staff did understand the importance of receiving someone’s consent before assisting them.

Although people had initially been involved in their plan of care, regular reviews had not taken place. The care plans were generic and did not contain enough information to assist staff in meeting people’s individual needs. People did not always feel their views were listened to.

People felt respected by the staff that supported them. They were treated with kindness and staff interacted with them in a courteous and warm manner. Their

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with five people who used the service, the registered manager and two members of staff. We also reviewed records relating to the management of the home which included, six care plans, daily care records, training records and support/supervision records of staff.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

During our inspection we spoke with five people who used the service or their spouses. They told us that they were happy with the care and support provided .

We looked at six sets of care records which included individual risk assessments. Measures had been put in place to minimise any risks to people who used the service that ensured they were supported safely. For example, risk assessments were in place to ensure that the environment in which care was provided was safe, that medication was safely administered and that people who needed to be moved with a hoist were transferred safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. While no applications had needed to be submitted, policies and procedures were in place and under review. Relevant staff had been trained to understand when an application might be necessary and how to submit one.

We discussed staffing rotas which showed that there were sufficient numbers of trained and competent members of staff employed to provide people with safe and appropriate care as identified in their assessment and care plans.

In a recent quality survey, 94% of people asked if they felt comfortable and safe scored the service good, very good or excellent.

Is the service effective?

People who used the service were treated with dignity and respect.

People who used the service were supported in making choices. For example, what to wear or what main meal they preferred. Where people found it difficult to make choices for themselves, staff supported them in making decisions based on best interest principles. We spoke with six people who used the service. Four of the people we spoke with told us that staff discussed their care plans with them, two others were unsure.

Quality assurance measures were in place to identify the effectiveness of the service. This included questionnaires given to people who used the service, relatives, staff and visiting professionals. We saw the results of a recent quality survey which showed that the service was effective.

Is the service caring?

We saw that people were cared for in an appropriate manner. Records we looked at showed that people’s needs had been assessed and details of likes, dislikes, routines and preferences were recorded.

During our inspection we spoke with six people who used the service or with the spouse. People told us that the care and support was good. One person said, "I can't fault them, I have had absolutely no complaints whatsoever." Another person we spoke with said the care provided, "Is very good, the carers are excellent and a real help." One person we spoke with, who was new to the service, told us, "They asked me lots of questions about the care I needed before it started and so far (after just over a week) I am very happy with them. My carer is very helpful and friendly."

The care records were based on person centred principles and individualised to meet the needs of the person in understanding and being involved in their care plan.

Is the service responsive?

The records we looked at showed that people's needs, choices and personal preferences had been assessed and planned for. Records we looked at during our inspection detailed the needs of each person and their individuality.

People’s health and social care needs were attended to. Information was available to staff about individual medical conditions to ensure that staff had up to date knowledge and were able to respond to the person’s needs.

Is the service well-led?

There were monitoring and reviewing systems in place to ensure that the quality of the care and support provided was high. Staff members told us that they had the training and support to safely do their job, which they said they enjoyed.

Members of staff and family members of people, who used the service, were provided with opportunities to make suggestions and comments to improve the quality of people’s support and care. These were developed into an action plan which identified the improvements made and ensured that the service was able to confirm when required improvements were completed.

Records we looked at showed that staff received regular support and supervision. This included an annual appraisal and three monthly spot checks to assess them in a practical setting whilst with people who used the service.

We reviewed the records of five people using the service and found that they all had complete and detailed assessment of their care needs, which included care planning. This care planning set out step by step instructions for staff on how to meet the person’s needs. We spoke with the relatives of two people using this service, one told us the service was, "Fantastic” and that “they're always there". Another relative told us, "The carers are brilliant, they're the best. No complaints at all".

We looked at the processes the service had in place to protect people from the risk of abuse. We found that there was an adequate safeguarding and whistleblowing policy in place, which detailed the process staff should follow if they had a safeguarding concern or felt the need to blow the whistle.

During an inspection visit on 5 March 2013, the service was identified as being non-compliant with requirements relating to workers, as they did not have full ten year employment history for their staff members, in line with regulations. This was followed up during this visit, and the service was found to be compliant, as they had now gained full ten year employment histories for the five staff members whose records we reviewed.

We found that the service was securely keeping accurate and up to date records for staff members and people using the service. A relative of a person using the service told us, "The records they keep in the home are brilliant and always up to date".

We found that most of the work of this agency was supplying staff to other registered service providers, acting as an employment agency. This did not fall within our remit to inspect. However, at the time of our inspection, eleven people were being provided with personal care in their own homes, and this was what we checked.

People using the service, or their representatives, told us that they felt very involved and consulted in drawing up plans of care. We could see that, where people did not have the capacity to understand this for themselves, efforts were still made to include them, and to ensure that decisions were made in their best interests.

We found that the recruitment procedure provided for checking references, seeking other relevant checks such as an enhanced criminal records bureau (CRB) check and interviewing staff. However, it did not provide for obtaining a full employment history as required by current regulations. The process did ensure that other checks were obtained and induction training was completed before staff started to provide personal care to people.

People made positive comments about staff, such as that they were "...respectful..." and that they felt "...completely confident..." with them. They felt very involved in decisions about their care, were happy with the support they received and had no concerns. They told us that they knew how to raise their concerns with the agency if they had any.

We spoke with three people using the service on the phone and they told us that they were happy with the service. They stated that carers were coming and staying for the agreed time. They stated that carers were good and knew what was expected of them. People felt safe and protected and said that they could contact the office if they were unhappy with anything. Two people confirmed that they knew about care plans and were consulted when care plans were reviewed.

People also made comments in the surveys recently carried out by the provider and some of the comments mentioned the good response to a complaint people made, with a timely and appropriate response from the out-of-hours service organised by the branch and indicated “very satisfied” with the service overall. A person stated in the questionnaire under “Any additional comments”: “Very swift service and sometimes you work miracles.”

Similar comments were seen in questionnaires returned from the social care establishments where carers from this branch worked. Managers of these establishments positively commented on carers’ reliability, skills and professionalism.