This inspection took place on 27 and 28 June 2018 and was announced

At the time of our inspection the service was providing packages of care to 18 people.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community [and specialist housing]. It provides a service to older adults and younger disabled adults. Not everyone being supported by Community Care Direct received personal care. The Care Quality Commission (CQC) only inspects the service being received by people provided with ‘personal care’; help with tasks relating to personal hygiene and eating. Where they do we also take into account any wider social care provided.

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.’

During our last inspection in June 2017, we found no breaches of any of the health and social care regulations however the service was rated as requires improvement. This was because the service had previously been rated as inadequate and placed in special measures and we wanted to ensure the service could sustain good practice.

Staff were recruited safely and checks were made on their character and suitability to work. Staff were only allowed to work once these checks came back as satisfactory.

Risks assessments were in place and were reviewed regularly. Risk assessments were suitably detailed and contained information with regards to the management ofrisk.

Medication was stored in people's own home and administered safely. Where staff were responsible for administering people's medication this was done by trained staff who had had their competency assessed.

Staff were provided with Personal Protective Equipment (PPE) such as gloves and aprons in accordance with the service's infection control procedure.

Staff were aware of safeguarding procedures and were able to describe the action they would take to ensure people were kept safe from harm. This included raising alerts to the registered manager, local authority safeguarding teams, the police, or whistleblowing.

Rotas showed that staff were assigned their care calls using an electric monitoring system (ECM). Staff were issued smart phones and were required to 'log' in and out of calls to ensure people were getting their allocated time. Records showed this system had been implemented since our last inspection.

The registered manager and the staff understood the principles of the Mental Capacity Act 2005 and associated legislation.

People were supported with eating and drinking and staff were aware of people’s dietary preferences.

Staff supported people to contact other healthcare professionals such as GP’s and District Nurses if they felt unwell.

Staff undertook training in accordance with the registered providers training policy. Staff told us they enjoyed the training. Training was a mixture of e-learning and practical training sessions. Staff spoken with confirmed they had regular supervision and appraisal.

Additional role specific training took place to help people manage their support needs. This training was overseen by a registered nurse who assessed staff competency once they had attended the training.

People we spoke with were complimentary about the caring nature of the staff and we received positive comments about the registered provider in general.

People told us that they were always kept informed and involved in their care.

We did not observe care being delivered, however, people told us staff were kind and caring in their approach.

Care plans contained detailed information about people, what their preferences were and how they liked their care to be conducted. I

This comprehensive inspection took place on 30 May 2017 and was announced.

Community Care Direct is a domiciliary care agency providing care to people with complex health needs in their own homes. At the time of the inspection Community Care Direct was providing care to 18 people and employed 36 staff.

Following an inspection in November 2015 the service was rated Inadequate and placed in special measures. Enforcement action was taken and we served a notice that restricted the service from accepting any new service users until the necessary improvements had been made. We inspected the service again in May 2016 and rated it Inadequate for a second time. At our inspection in November 2016 the service was rated as inadequate for a third time with persistent breaches of regulation. The service remained in special measures while the Commission considered its regulatory response.

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. At this inspection we found improvements in all areas and all previous breaches of regulations had been met. Because of the improvements the overall quality rating has been raised to ‘requires improvement’ and the service has been removed from special measures.

A registered manager was 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.

At the previous inspection we found that the service was in breach of regulation relating to safe care and treatment and in particular; the management of risk, safe management of medicines and the management of incidents and accidents.

We found that risk assessments had been significantly improved. Each record contained an environmental risk assessment as indicated in the provider’s action plan and other records were sufficiently detailed and showed evidence of regular review. The service was no longer in breach of regulation in this regard.

At the previous inspection we identified a concern with the clarity and consistency of records relating to the administration of medicines. As part of this inspection we checked a sample of Medication Administration Records (MAR’s) and saw that they were completed correctly.

At the last inspection we were provided with information to suggest that incident and accidents records had not been completed as required or that appropriate action had not been taken following incidents and accidents. We saw that records were completed in sufficient detail and had been analysed to look for patterns and trends which could help reduce risk in the future. The service was no longer in breach of regulation in this regard.

At our last inspection we found that the service was in breach of regulation because consent was not always considered in accordance with the principles of the Mental Capacity Act 2005 (MCA). At this inspection we saw the service was operating in accordance with the principles of the MCA and was no longer in breach of regulation relating to consent.

At the last inspection we found the service to be in breach of regulation because the quality of communication with staff was not consistent. This meant that people were at increased risk of calls being delayed or missed. As part of this inspection we checked paper-based and electronic communication records to ensure that they were complete. The records that we saw were significantly improved since the last inspection. Each communication was clear and resulted in an action where appropriate. The service was no longer in breach of regulation in this regard.

At the last inspection we received information of concern indicating that staff did not always stay for the duratio

This comprehensive inspection took place on 28 November 2016 and was announced.

At the inspection in November 2015 the service was rated inadequate and placed in special measures with breaches of regulations 9, 10, 11, 12, 13, 16, 17, 18 and 19. At our next inspection in May 2016 the service was again rated as inadequate with continued breaches of regulations 9, 10, 11, 12, 16, 17, and 18. Following the inspection in November 2015 enforcement action was taken and we served a notice that restricted the service from accepting any new service users until the necessary improvements had been made. This restriction remained in place following the inspection in May 2016. We found that the agency had adhered to this legal requirement at the time of our inspection.

Community Care Direct is a domiciliary care agency providing care to people with complex health needs in their own homes. At the time of the inspection Community Care Direct was providing care to 26 people and employed 35 staff.

A registered manager was 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.

At the last inspection in May 2016, we asked the provider to take action to make improvements in relation to person-centred care, dignity and respect, need for consent, safe care and treatment, receiving and acting on complaints, good governance and staffing.

Actions in relation to receiving and acting on complaints, dignity and respect and staffing had been completed. Actions in relation to consent, person-centred care, safe care and treatment and good governance had not been completed and the service remained in breach of regulation in these areas.

We looked at five care records to evaluate risk assessment processes and documentation. We also looked at the guidance given to staff to safely manage risk. We saw that some risk assessments were not present in care records and other risk assessments were lacking detail.

Medicines were not administered and recorded in accordance with best-practice guidance. Some records were incomplete and did not provide staff with clear guidance. Other records were difficult to read. PRN (as required) medicines were not administered safely or in accordance with instructions.

Before the previous inspection we received information of concern relating to poor infection control practice and the distress that this had caused to a person using the service. The service was in breach of regulation in this regard. We checked training records and asked the registered manager what action had been taken to improve practice in this area. We saw that additional training had been provided to all staff, guidance had been circulated and spot checks completed. The service was no longer in breach of regulation in relation to infection control.

Incident and accidents records had not been completed as required and appropriate action had not been taken following incidents and accidents.

Consent was not reviewed when care needs had changed. For example, one person was identified as having fluctuating capacity because of a health condition. Concerns were raised about their capacity to give consent at the last inspection. We saw that this potential lack of capacity had not been addressed within the care plan or consent documents.

The quality of communication between care workers and the service was inconsistent. During this inspection we checked to see what progress had been made by looking at the communication books. We saw numerous examples where information was limited and there was no evidence of action taken as a result of information being shared.

The provider’s action plan for achieving compliance with the requirements for delivering person-centred care includ

This comprehensive inspection took place on 19, 20 and 23 May 2016 and was announced. At the previous inspection in November 2015 the service were rated inadequate and placed in special measures with breaches of regulations 9, 10, 11, 12, 13, 16, 17, 18 and 19. Enforcement action was taken and we served a notice that restricted the service from accepting any new service users until the necessary improvements had been made. We found that the agency had adhered to this legal requirement at the time of our inspection.

The agency provides care to people who have complex care needs such as palliative/end of life care, spinal injury and neurological conditions such as Parkinsons Disease and Multiple Sclerosis. At the time of our inspection there were 35 people using the service and 44 staff employed.

We found despite some improvements being made since our last inspection, such as an improved recording of messages in the communication book, we remained concerned that the service delivery was to suit the service and not the people receiving the service. We were also concerned that the registered manager had failed to demonstrate that they had actively listened to people and done everything possible to improve the care for people. People were still at risk of harm.

There was a registered manager in post at the time of our inspection. 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 found a system in place whereby the registered manager was visiting people to review their care but we did not see a system of transferring that information in the care plans to ensure the information in the care plans was up to date. We found care plans were also not being reviewed when changes occurred. Therefore, we could not be sure the information was up to date. We found that although new processes had been implemented, the information was not always being recorded appropriately.

We found the service were still not reviewing people's mental capacity.

A new on-call system had been put in place since our last inspection and a more thorough recording system of any messages received however, it was not always clear what action had been taken.

Staff told us that they have an online system in place to complete training in addition to their classroom training. Staff we spoke with told us they had received supervision in the last six months.

The registered manager had implemented new policies such as the Quality Control/Assurance Audit Record and Policy and completed survey questionnaires with staff and people who use the service. Of those returned, we could not see any evidence of learning from the comments or answers being given. We also did not see any evidence of learning from complaints, safeguarding’s or accidents.

An incident logging system had been put in place however it was not robust enough to ensure information was being recorded appropriately.

There had been an improvement to staff rotas as staff were now receiving them a week in advance. However there was still not enough staff to ensure people were safe and their needs were met in a timely way.

We looked in staff recruitment files and found there were systems in place for recruiting staff. Some people we spoke with were unhappy with the delivery of care in relation to the timings and duration of their calls.

We viewed MARS (Medication Administration Record Sheets) sheets and they were being signed when medication was administered. However, we found for one person there were gaps on occasions where the person required prescribed creams to be applied.

Staff were able to tell us what they would do in the event that they were concerned about abuse and how they would report it. Safeguarding trai

We carried out an unannounced comprehensive inspection of this service on 14th, 15th and 20th January 2015 when two breaches of legal requirements were found. The breaches of regulations were because we had some concerns that staff were not recruited safely and quality systems were not consistently applied or embedded to monitor the service and to assess and manage risks to people who used the service.

We asked the provider to take action to address these concerns. After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches.

We undertook a focused inspection on 21st July 2015 to check that they had now met legal requirements. This report only covers our findings in relation to these specific areas / breaches of regulations. They cover two of the domains we normally inspect; 'Safe' and ' Well led'. The domains 'Effective', 'Caring' and 'Responsive' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Community Care Direct' on our website at www.cqc.org.uk.

Community Care Direct is a 24

twenty four hour domiciliary care provider based on a busy high street close to the centre of Southport. They provide domiciliary / in-home care, palliative care and a 24

twenty four hour live in services.

At the time of the inspection the home did not have a registered manager. 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 and associated Regulations about how the service is run.  At the time of our inspection there was a new manager in post and they informed us they were applying for the position of registered manager. Following our inspection the manager informed us they had submitted their application for registration with the Care Quality Commission.

At the time of our inspection the manager informed us the agency were providing a service for 45 people. During this inspection we met with the manager, the provider and three members of the staff team. Following our inspection we spoke with two relatives to gain their views about the service.

At this inspection we found improvements had been made in all areas and the previous breaches had been met. Recommendations in some key areas to improve practice had

were also been implemented.

We checked staff recruitment files and saw recruitment checks were in place to ensure staff were suitable to work with vulnerable people. The manager had completed an audit of the files and we saw recruitment checks were more thorough.

We looked at how the service was monitored. Systems and audits (checks) were now more consistent to help to assure and develop the service.

We considered all the evidence we gathered under the outcome we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found –

Is the service safe?

We found that the provider had effective recruitment processes in place. We looked at four staff files which evidenced this.

Is the service effective?

Staff had received training which helped ensure people`s needs were met and kept them safe. We saw evidence new staff had received an induction and training to support them in their job.

Is the service caring?

This was a responsive inspection to concerning information and we did not look specifically at this area.

Is the service responsive?

This was a responsive inspection to concerning information and we did not look specifically at this area.

Is the service well led?

This was a responsive inspection to concerning information and we did not look specifically at this area.

People and their relatives told us they were involved in the initial assessment of their care needs and in agreeing what support they required and when it should occur. We saw signed contracts showing that people or their representative had given their consent to receiving care and support from Community Care Direct.

The care plans we viewed provided details about the care and support each person required based on their individual assessments. Overall people spoke positively about the care they received. Comments included; “The service is very reliable. There have been some staff changes recently which means you have to show new staff ‘the ropes,’” and “Staff are very pleasant and I have confidence in them.”

We looked at the systems in place for managing medicines. The agency only provided people with support and assistance with their medicines where it was specified as part of their individual care needs and where the medication was prescribed by their GP.

Most people we spoke with said care workers usually came on time and stayed for the full length of their allocated call time. Staff we spoke with told us they attended specialist training to support people with specific health needs.

All care records were securely retained by the agency to maintain confidentiality. The Registered Manager was knowledgeable about the safe storage and destruction of care records and other confidential information.

The office is based on a busy high street near to the centre of Southport, there are no parking facilities but on street parking is available nearby. Community Care Direct (CCD) provides care twenty four hours a day and also offers an out of hours emergency on call service for staff and service users and their relatives. This service covers all weekends and bank holidays. We spoke to two people who use the service and three members of staff during this inspection.

People told us;

"I ask and they provide it is a great service"

"I have used them for years first for my wife and now for myself, I tell them what i want and they can provide. Darren comes out to see me everytime I want to change the package nothing is too much trouble"

"The girls really look after me and I trust them which is a big thing for elderly people"

Staff told us;

"I left to work somewhere else but came back, I now know what its like to feel supported and valued in my job"

"Even if you have personal problems the managers will try and help you, they really look after you."

"I enjoy caring for people it is rewarding and has led me to decide to start my nurse training"

"The most rewarding part of my job is knowing I have made a difference to someone and that they appreciate my efforts"

Community Care Direct Limited is a 24 hour domiciliary care provider based close to the centre of Southport.  At the time of our inspection the agency were providing personal care to approximately 63 people in their own homes. We were later informed by the service that the number of service users reduced to 37 in December 2015.  The agency provides care to people who have complex care needs such as palliative/end of life care, spinal injury and neurological conditions such as Parkinson’s Disease and Multiple Sclerosis. 

A registered manager was not in post at the time of inspection due to termination of their employment by the provider which triggered the inspection. ‘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.’

At the last inspection dated 14, 15 and 20 January 2015 there was a breach of Regulation 21(a) and (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 for not having safe recruitment practices.  By not having robust systems in place to assure the quality of the service was a breach of Regulation 10 (1) (a)(b)(e) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A focused inspection dated 21 July 2015 was undertaken to check if Community Care Direct Limited were meeting legal requirements.  The domains ‘Safe’ and ‘Well-led’ were covered during the inspection. Following the inspection the manager had submitted their application for the position of registered manager.  At this inspection we found improvements had been made in all areas and the previous breaches had been met. Recommendations in some key areas to improve practice had also been implemented.

At this latest inspection the provider told us they were recruiting for a manager and for additional staff.  We determined how many staff were working within the service by the staff list handed to us during inspection.  We then asked for the staff list to be reviewed and revised as we found some staff were on the list who were no longer working there or new staff had not been added to the list. We established from the revised list there were 45 staff working for the service.  Not all staff had received safeguarding training including two new staff, one of whom had no previous experience working in care.

We looked in staff recruitment files and we found that robust checks had not been put in place to ensure people were always safeguarded from potential harm or abuse.   Staff training was incomplete with some new starters who were not receiving monitoring of their performance during their probationary period to ensure they were performing well in their role. Staff we spoke with were not receiving supervision and there was no appraisal system in place to enable staff to seek support and continuous improvement of their practice. 

Risk assessments for people who received a service were either absent or incomplete with basic information for people with complex health care needs placing them at high risk.  Risk assessments which were present in the care plans were not dated/signed or did not provide detailed person specific information to mitigate the risks.  

We visited four people who used the service with their permission and they all told us the staff were pleasant and they had confidence in the staff who they receive care from.  As part of the inspection we also contacted people by telephone.  Some people told us they were happy with the service they received and others expressed concerns about the service. All the people we visited told us of late calls, calls not lasting for the duration of time planned to receive care or missed calls.

Some staff expressed they were happy with the service Community Care Direct provided to people.  However, other staff told us they were unhappy with the rota system. They told us they were not provided with adequate travel time in between calls.  Other staff and also people using the service  we spoke with  said further calls were added into the rota on the day resulting in staff being late to provide care to each person.   

We found systems which were in place including the on call system and complaints system were not robust and did not meet people’s needs.  

The service had no policy regarding consent and consent documentation we found was not completed, signed or dated. 

The service lacked good governance as we did not see any evidence of audits being completed. We did see evidence of a quality assurance questionnaire sent to service users in March 2015.

You can read about what action we told the provider to take in the action section at the back of the full version of this report.

The overall rating for this provider 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.

Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. 

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.