We carried out an announced inspection of Excel Care Management on 21 and 22 May 2018. We also gathered the views of people who used the service, their relatives and staff members via telephone calls and emailed questionnaires between the 22 May 2018 and 05 June 2018. Although the service had moved office from Atherton to Leigh since our last inspection, the service history was not affected because care and support is provided to people in their own home.

Excel Care Management is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to people living with dementia, older people, children and people with a physical disability or autistic sensory impairment. The service is a member of the local authorities ‘Ethical Community Services Framework’ and was awarded the contract for provision of care in Leigh. At the time of the inspection, there were 129 people receiving a service from Excel Care Management.

The service was last inspected in March 2017, when we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to good governance (two parts of the regulation) and staffing. Following this inspection, the service was rated as requires improvement overall and in the key lines of enquiry (KLOE's); safe, effective, responsive and well-led. The service was rated as good in caring.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; safe, effective, responsive and well-led to at least good. The service has been provided ongoing support and monitoring by the local authority through the ‘Ethical Framework’. We reviewed the progress the provider had made as part of this inspection and found that all the breaches identified at our last inspection had been fully addressed. At this inspection the service was found to be complaint with all the regulations.

At the time of the 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.

All the people and their relatives we spoke with said they felt the service was safe. We saw there were suitable safeguarding policies and procedures in place. Staff had all received training in safeguarding vulnerable adults and demonstrated a good understanding of how to report both safeguarding and whistleblowing concerns.

We saw effective recruitment procedures remained in place to ensure staff working for the service met the required standards. The registered manager had also implemented pre-interview telephone screening to ensure staff had the required values before progressing to formal interview.

At our last inspection we identified concerns with documentation relating to the management of medicines. At this inspection, we confirmed medicines were managed safely, all guidance to support the safe administration of medicines were in place and audits completed timely to ensure signature omissions had been identified and addressed.

The provider had appropriate assessments in place which were reflective of people’s needs and provided guidance for staff on the measures needed to reduce risks. There was an effective system in place to manage accidents and incidents, and to reduce the likelihood of re-occurrence.

Since our previous inspection, staff had received a comprehensive training programme and were working towards the care certificate with an identified timeframe for completion. Staff had a personal development plan (PDP), received quarterly supervision and staff in post over a year had completed an annual appraisal.

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Excel care management is a domiciliary care agency, which provides personal care and support to people in their own home. The service provides support to people living in Leigh and the office has recently moved to Leigh to support the care delivery. At the time of our inspection, there were 82 people using the service. The service is part of the ethical framework for community services in Wigan so the majority of people who used the service had their care funded by the local authority.

The inspection took place on 15 March 2017 and was announced. We gave the provider of the service 48 hours' notice of the inspection. This was because the location provides a domiciliary care service. We needed to be sure that the manager would be available to speak with us.

Our last inspection of Excel was in December 2015 where the service was rated as ‘Requires Improvement’ overall and for the key questions of Safe, Effective, and Well-led. The key questions for Caring and Responsive were rated as Good.

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to good governance (two parts of the regulation) and staffing. You can see what action we have taken at the back of the full version of this report.

The service had 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.

There were appropriate policies and procedures in place. Staff demonstrated a good understanding of safeguarding, whistleblowing and how they would report concerns.

We found medicines were managed safely but there was no information recorded to guide staff when administering medicines which were prescribed to be given “when required” (PRN). The registered manager commenced addressing this during the inspection and sent confirmation that this had been rectified.

We saw employment checks had been conducted prior to staff commencing with the service and current staffing levels were sufficient to meet the care packages. People told us missed visits were not a regular occurrence and that staff were generally on time for the scheduled visit.

People did not always have risk assessments that reflected their current needs or care plans to mitigate these risks. Staff did not have detailed guidance about the care people required.

We found there were gaps in records. People did not have sufficient guidance recorded to mitigate risks and the registered manager was unable to demonstrate how they captured, reviewed and monitored any trends or patterns for accidents and incidents or shared information with staff to prevent re-occurrence and to promote learning.

Staff received an induction that was aligned with the care certificate. We saw there were gaps in the training staff received which meant the provider had not ensured staff had the required knowledge and skills to support them to fulfil the requirements of their role.

We found people did not consistently have the required support plans in place and staff were following an overview of people’s support needs which was prescriptive detailing how care was to be delivered and did not incorporate individualized, measurable and achievable goals.

People were complimentary about the staff and support they received. People were supported by a regular staff team and told us they were treated with dignity and respect and felt able to contribute to the care they received.

People were encouraged to engage in activities and a complimentary service had been developed to enable people to access two hours per month support to engage in activities of their choosing.

There were systems in place to monitor the quality of the service b

The inspection took place on 22 December 2015. We announced the inspection 48 hours prior to our arrival in order to ensure someone would be in the office to facilitate our inspection. We also telephoned people who used the service and their relatives on 23 December 2015. This helped us seek feedback about the quality of service provided.

Excel care service provides support to people living in their own homes in Leigh, Atherton, Bolton and the surrounding areas. Referrals are made from continuing health care, direct payments and private customers. Excel care support people with personal care and support to enable them to live in their own homes. At the time of this visit there were approximately 100 people using the service.

The service had 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.

We identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Safe Care and Treatment, Good Governance, Staffing and Fit and proper persons. You can see what action we told the provider to take at the back of the full version of the report.

During the inspection we checked to see how the service managed and administered medication safely. We found people were not always protected against the risks associated with medicines, because the provider did not have appropriate arrangements in place to manage medicines safely.

We found the medicine administration records (MAR) and care plans did not contain adequate information to guide staff on how to give them. We found information was not consistently recorded to guide staff on the dose that should be given, the form the medication came in (such as tablet or liquid) or in what circumstances ‘when required’ (PRN) medicines should be given. It was important this information was recorded to ensure people were given their medicines safely and consistently at all times.

We looked at eight MAR, whilst at the office. We found repeated omissions/ signature gaps in all the records. We looked at internal medication audits undertaken by the service and noted a theme of signature omissions during 2015. Though issues were identified, action had not been taken to address these issues with the individual staff concerned. We found that records failed to demonstrate that people had received their medication safely and in line with their prescription. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

We found the registered manager was unable to demonstrate how they captured, reviewed and monitored any trends or patterns for accidents and incidents or shared information about them with the staff to prevent re-occurrence and to promote learning. This was a breach of 12(2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A number of staff had unexpectedly left the service which had impacted upon the consistency of staff visits. The registered manager identified recruitment and retention of staff as a challenge to service delivery. We saw recruitment had been compromised and the registered manager was unable to demonstrate they were consistently making safe recruitment decisions. This was a breach of Regulation 19 of the Health and Social Care Act 2008 Regulated Activities) Regulations 2014.

Procedures were in place regarding safeguarding and whistleblowing. Staff had a good awareness of safeguarding, how to report concerns about people’s wellbeing and what they had to do to keep people safe.

Staff received an induction and shadowed experienced care staff until they felt confident to provide care independently. Staff had regular supervision and reported feeling supported. We saw staff undertook mandatory training but noted there were shortfalls in the training as it did not cover specialist topics such as; dealing with challenging behaviour. This training was required to enable staff to fulfil the requirements of their role. This is a breach of Regulation 18 (2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to Staffing.

People were looked after by care workers that were kind and caring and promoted people’s independence and maintained their privacy and dignity. Despite not receiving MCA training, people’s rights in making decisions and suggestions in relation to their support and care was valued and acted upon. We found that before any care was provided, the service obtained written consent from the person who used the service or their representative. We were able to verify this by speaking to people and from reviewing care records.

People and their relatives were involved in the initial assessment process to ascertain people’s needs and how they wanted care to be provided. Care plans were personalised and contained detailed information about the support people required to meet their needs.

Quality assurance systems were not robust. The registered manager had undertaken audits in regards to the practices and records at the service to ensure people were receiving safe care. However, we found that these were not always effective. The systems had not addressed gaps in the management of medicines, accidents and incidents, staff training and recruitment. The registered manager had also not consistently developed action plans to show how issues identified in audits were being addressed and monitored. This was in breach of regulation 17(1)(2)(a)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Feedback had been sought from people, relatives and staff. Team meetings were held but actions were not consistently demonstrated to promote service improvements.

People, relatives and staff we contacted were confident witht the management team and described them as approachable and feeling supported.

Providers are required by law to notify CQC of certain events in the service such as serious injuries, deaths and safeguarding concerns. We found two incidents which had occurred at the service where CQC had  not received the required notifications from the service.

People spoken with said that the senior staff had discussed care plans with them.

They said that staff were "really great," “ the staff always ask me what I want and go beyond the call of duty, ” ” they do whatever I need them to do,” " staff are excellent, " " I can’t fault the staff ” and "really good staff .”

People spoken with said that they knew who to speak with if they had any issues or concerns. They said " I can sort things out with the people in the office" and " I have no complaints staff are brilliant ."

Staff spoken with confirmed that training takes place, they are supported and have formal supervision.

They all said that it was a good place to work.

Comments such as "very happy with the service” “ staff are marvellous they go the extra mile” and " the staff are very good never have any trouble" were made.

We visited Excel Care Management Services on 12 February 2013. We looked at the care records for people who used the service. We saw that care records for people who used the service had been discussed with them and their consent had been obtained.

We visited and spoke to people who used the service. We saw that care records in the homes of people who used the services were individual and personalised. Daily record sheets in all the homes we visited were up to date. People who used the service told us: “I’m very happy with them, they’re very good”.

We found that staff had received training in the safeguarding of vulnerable people and the staff we spoke to were aware of policies and procedures in place to help protect people using the service from harm or abuse.

We spoke to a professional from one of the local authorities who had involvement with the service and they had no concerns at the time of our inspection.

We found that there was a robust recruitment process in place. All relevant checks on staff had been completed and the staff we spoke with confirmed this process. This meant that people who were employed by the service were of good character and suitable to perform their job.

We looked at the systems in place for the storage, and recording of information for people who used the service in the office and checked that it corresponded with records kept in peoples own homes. We found that recording systems were fit for purpose.

“I have no problem at all: the girls always act in a very professional way.”

“They always arrive on time and very often stay longer to finish what they are doing.”

“They are always very pleasant and nothing is too much trouble.”

“The carers are fantastic: they can’t do enough for you.”

“The carers are really very good: I had another service previously and these are far better.”

“I am very pleased with the information we get from the service.”