Overall summary & rating - Requires improvement

Updated 27 March 2020

About the service

Say Care Limited is domiciliary care agency which provides support and personal care to people living in their own home. Not everyone using Say Care Limited received a regulated activity; CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also take into account any wider social care provided. At the time of our inspection 32 people were receiving a regulated activity from the service. People’s experience of using this service and what we found People were supported by staff who knew how to prevent and manage risks and keep them safe from avoidable harm. However, at the time of the inspection recruitment practices were not always robust. This was immediately addressed. Systems to monitor the quality and safety of care delivered were not always robust to allow timely actions to be taken. There were sufficient numbers of consistent staff available to meet people’s needs. People received continuity of personal care and support from staff who arrived on time for their scheduled visits and were familiar with their needs and wishes. People received their medicines as they were prescribed. The service's arrangements for controlling infection remained effective. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff received some training to give them the skills to support people with their needs. The registered manager was in the process of ensured all staff training was updated in a timely way. People were supported to maintain a nutritionally well-balanced diet, where required and to access health and social care professionals if needed. The registered manager worked in close partnership with health and social care professionals and agencies to plan and deliver people's packages of care and support. People told us they remained happy with the home care service they received from Say Care Limited and were positive about all aspects of the service. All the people and relatives we spoke with praised the staff and registered manager for their kind, respectful and supportive approach. People were encouraged and supported to remain independent. Some people’s care plans contained inconsistencies in the amount of person-centred information that was recorded, however the registered manager was able to demonstrate that this was being addressed. Care staff demonstrated they knew people well and understood their likes, dislikes and preferences. People were encouraged to make decisions about the care and support they received and had their choices respected. People were confident that if they raised any issues, concerns or complaints these would be dealt with effectively by the registered manager. People and their relatives felt the management team were open, approachable and supportive. They were responsive to feedback from people, staff and professionals and acted to make improvements in the service. For more details, please see the full report which is on the CQC website at www.cqc.org.uk Rating at last inspection The last rating for this service was Good (published 21 August 2017). Why we inspected This was a planned inspection based on the previous rating. Follow up We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Safe - Requires improvement

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. Staffing and recruitment

● People were not always protected from the risk of being supported by unsuitable staff as recruitment processes were not always robust. Whilst some of the necessary recruitment checks were in place, for example, disclosure and barring service (DBS) checks had been completed, some improvements were needed.

● We viewed recruitment records for three staff members and found that some recruitment checks had not been completed. Two recruitment records viewed showed that although two references had been requested for each of these staff members, none had been received prior to employment or since. The registered manager and nominated individual told us for one of these staff members previous employment was seasonal so they had been unable to obtain these references. However, there was not a process in place that demonstrated when this occurred additional references were requested.

● Due to the issue highlighted above, the service could not be assured that staff recruited were of good character or suitable to work at the service. However, we did not find any evidence that the recruitment processes had an impact on people as there was a small consistent team of staff available to people and new staff worked alongside experienced staff. All the people we spoke with, told us they had no concerns with the staff employed by the service and spoke positively about all staff.

● The recruitment issues found were discussed with the registered manager and nominated individual who agreed to review the recruitment processes in place. Following the inspection, we were sent further information which evidenced that this had been done and appropriate actions had been taken.

● There were sufficient numbers of staff to meet people's needs. Staff had adequate time to travel between visits to people. The service ensured people were supported by small teams of care staff, who were located within the same area. This ensured they had enough time to visit people according to their set schedules.

● People told us that staff had enough time to meet their needs and support them without being rushed. One person said, "They do what I need them to, I have no grumbles at all." Another person told us, "The staff are always on time and will do what I need. Recently I had a few problems and the staff stayed and provided extra support, nothing was too much trouble."

● Relatives comments included, "The service is very good and reliable. The care staff arrive when they should and stay as long as they need to", "Me and my mum are very happy with the service" and "The staff always arrive on time." Systems and processes to safeguard people from the risk of abuse

● People said they felt safe. A person said, "Oh, I definitely feel safe with the staff." Another person told us, "I feel very safe, the care is flawless." A relative said, "I am not at all concerned about [loved one's] safety."

● The provider had suitable systems in place to ensure staff were aware of how to safeguard people from Requires Improvement 8 Say Care Limited Inspection report 26 March 2020 harm and abuse.

● There were processes in place for investigating any safeguarding incidents. The registered manager was able to describe actions they would take if abuse was suspected.

● Staff were knowledgeable in recognising signs of potential abuse and understood the relevant reporting procedures. A staff member said, "I would report any concerns on to [name of registered manager], they would take action." Another staff member told us, "If I had a safeguarding concern I would go to my supervisor or the manager, they would do something about it, but if I needed to I would report to the safeguarding team or CQC." Assessing risk, safety monitoring and management

● Risks to staff and people who used the service were assessed and managed.

● Risk assessments were in place to minimise risks. These gave staff guidance about how to reduce risks to people.

● Completed risk assessments included; medicines, falls, food, nutrition, pressure injuries and skin conditions. Staff were knowledgeable about people's individual risks and the steps required to keep people safe.

● People's home and environmental risk assessments had been completed by the registered manager and senior staff to promote the safety of both the staff and people. As well as considering the immediate living environment of the person, including lighting, the condition of property, electrical items and security, risk assessments had been completed in relation to the safety of the location. For example, if street lighting was poor or the home was in a rural area. All risk assessments were reviewed annually or more frequently if needed.

● Say Care Limited had a lone worker system in place to promote staff safety. This system relied on the person receiving care to alert the office staff or out of hours supervisor if the member of the care staff had not arrived at their care call within 15 minutes of the allotted call time. Using medicines safely

● Medicines continued to be managed safely and people received their medicines when they should.

● Where people were supported to take their medicine, medicines administration records (MAR) were kept in their homes. These records were checked by a member of the management or administration team when they were returned to the office to ensure that the medicine was being given as prescribed.

● People and relatives told us they were happy with support received in relation to medicines. Comments included, "They put my medicine on a spoon for me to take, it works well" and "They check I have taken my tablets and write it down."

● Staff told us they had received medicine training and their competency was checked to ensure their practice in medicines administration was safe.

● Care plans included information as to the level of support people required with their medicines and who was responsible for collecting prescriptions. Preventing and controlling infection

● The provider had an infection control policy in place and staff undertook training in this area.

● Staff had access to and used protective personal equipment (PPE) such as disposable gloves and aprons. This meant staff and people they supported were protected from potential infection during the delivery of personal care.

● People told us staff wore PPE when they were being supported with personal care. Learning lessons when things go wrong

● Staff completed reports when a person had been involved in an incident or accident. We found the 9 Say Care Limited Inspection report 26 March 2020 information within the reports to be detailed; identifying the type of incident, who was involved, a brief description and the outcomes with any actions which were taken to reduce future risk. These were then checked by senior staff to ensure appropriate actions had been taken.

● The information of incidents and accidents that occurred were recorded in people's individual care records. However, we found there was not a service wide process in place to review all incidents and accidents as a collective. This meant that although themes and trends were identified and acted on an individual basis wider themes and trends may not have been identified. This was discussed with the registered manager and nominated individual who agreed to implement a system to address this.

Effective - Good

Effective – this means we looked for evidence that people's care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At the last inspection this key question was rated as Good. At this inspection this key question has remained the same. This meant people's outcomes were consistently good, and people's feedback confirmed this. Assessing people's needs and choices; delivering care in line with standards, guidance and the law

● People's needs were assessed prior to the service starting. This was to ensure their needs could be met. People and relatives confirmed care needs and wishes were discussed with them before care was commenced.

● Following the assessment, a care plan was developed detailing the person's needs, wishes and level of care required.

● When required the registered manager and senior staff liaised with health and social care professionals to develop the person's care plan based on best practice and current guidance.

● Staff applied learning effectively in line with best practice, which led to good outcomes for people and supported a good quality of life. Regular checks of staff practice helped to ensure people received high quality care.

● People were involved in making every day decisions and choices about how they wanted to live their lives and described the service as effective. A relative said, "They are always very accommodating, we get the service we expect, as agreed." A person told us, "The service is tremendous, I get exactly what I need when I need it, even at short notice." Staff support: induction, training, skills and experience

● New staff were required to complete a detailed induction programme before working on their own. This included completing essential training for their role and shadowing an experienced member of staff. A relative confirmed new staff were, "introduced and work alongside a current member of staff" before attending the their loved one independently.

● People who used the service and their relatives described the staff as being well trained. A person told us, "I think they know what they are doing." Another person said, "They are trained very well." A relative said, "On the whole they know what they are doing."

● Staff told us they received the training they required to help them fulfil their role. A staff member said, "We get lots of training." Another staff member told us, "The training is very good. If there are specific things I feel I need to know more about, I only have to ask and this will be provided."

● There was a system to record the training that staff had completed and to identify when training needed to be repeated. The records viewed confirmed staff had received some essential training to a timely way to help ensure that safe care was provided to people. This included training such medicines management, safeguarding adults, mental health and moving and handling. However, other areas of training to further support staff had not always been updated in a timely way. Including, equality and diversity, food safety and infection control. This was discussed with the registered manager who was able to provide assurances this issue was being addressed. Good 11 Say Care Limited Inspection report 26 March 2020

● Staff received regular supervision sessions with a member of the management team. Supervisions was provided in a variety of formats including, one to one, face to face supervision, observations of staff practice and team meetings. These provided the management team and staff with an opportunity to gain feedback on their performance, identify any concerns, and agree learning opportunities to help them develop. Staff employed longer than 12 months had received an annual appraisal of their overall performance. All staff spoken to told us they felt very well supported by the management team. Supporting people to eat and drink enough to maintain a balanced diet

● Where needed the staff ensured people were supported to have good levels of hydration and nutrition.

● If reduced appetite or weight loss was suspected by staff, food and fluid charts were implemented and reviewed to monitor dietary intake. The registered manager told us, "If concerns to a person's diet was noted, staff would contact the office and a healthcare professional would be contacted."

● People told us they were happy with the arrangements in place to support them with their meals. One person said, "They get my breakfast for me, they always check with me about what I want." A relative told us, "[Loved one] is always offered drinks on each visit and meals are prepared and served as necessary." Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier lives, access healthcare services and support

● People had care plans in place, which contained information about their general health, current concerns and abilities. This was shared appropriately if a person was admitted to hospital or another service and allowed person centred care to be provided consistently.

● Staff worked well with external professionals to ensure people were supported to access health and social care services when required.

● Staff confirmed where people's health needs deteriorated, they were able to support people to access medical support, if required.

● The registered manager told us if people required an unexpected hospital admission staff would be made available to support with this and accompany them to hospital. The registered manager said, "We would go with people to hospital, we would never want them to be on their own." Ensuring consent to care and treatment in line with law and guidance The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. We checked whether the service was working within the principles of the MCA.

● The registered manager and the staff were aware of their responsibilities under the MCA and the role they might play in care delivery.

● No one in receipt of care was under any authorisation of the MCA but the registered manager would alert social care professionals if there were any matters where people were being deprived of their liberty.

● People confirmed they were asked for their consent from staff before care was provided.

Caring - Good

Caring – this means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect.

At the last inspection this key question was rated as Good. At this inspection this key question remained the same. This meant people were supported and treated with dignity and respect; and involved as partners in their care. Ensuring people are well treated and supported; respecting equality and diversity

● The management team led by example, by working hands-on and motivating staff to deliver good care. The caring nature of the service was shared by all. People, relatives and care staff spoke of a management team that put people first. Comments included, "The company is run with love", "The owners properly know people and are so considerate to people and staff" and "I can't speak highly enough of this agency, they are hands on, they are amazing."

● All the people and relatives we spoke with were happy with the care provided and spoke positively about the staff. A person said, "Everyone was so kind and patient." A relative told us, "We have found them all [staff] to treat [loved one] with the utmost amount of respect and dignity including when personal care has been needed." A relative told us, "I can't praise them enough, I really can't fault anything, they are so very gentle and kind."

● People were supported by a consistent team of staff which allowed trusting relationships to be built. A relative said, "We have regular staff who have built up a good relationship with both [loved one] and us [family]."

● All the staff members spoken to were enthusiastic about their roles and told us they enjoyed their job. One staff member said, "I love everything about my job, I love listening to people. I think it's a very caring team of staff." Another staff member told us, "Everything about this job is good and it's lovely to be able to help people."

● Individuality and diversity were respected. This was achieved by identifying where people needed support. There were no indication people protected under the characteristics of the Equality Act would be discriminated against. The Equality Act is legislation that protects people from discrimination, for example on the grounds of disability, sexual orientation, race or gender. Supporting people to express their views and be involved in making decisions about their care

● People and their relatives told us they were fully involved in making decisions about the care provided and had been involved in the development of their care plans. We saw care plans had been signed by the person receiving support or their representative.

● People and their relatives told us they were frequently asked by care staff, senior staff and the registered manager if they were happy with the care provided. They also confirmed that care arrangements were reviewed regularly to help ensure care was provided as required.

● A person said, "They [care staff] know that I can make my own decisions, they always listen to me and ask me first about what I need." Another person told us, "It is always my decision about what happens when the carers are with me. We have a plan but if I want things done differently I only have to say." Good 13 Say Care Limited Inspection report 26 March 2020 Respecting and promoting people's privacy, dignity and independence

● All people we spoke with told us staff respected their privacy and dignity. A relative said, "They [staff] are respectful of us and our home. They will always knock on the door before coming in and check with us before doing anything."

● Staff understood their responsibilities when respecting people's privacy. A staff member described how they ensured people's privacy was maintained during personal care. This included, shutting curtains and doors and keep the person covered as much as possible.

● Confidential information, such as care records, was kept securely within the office and only accessed by staff authorised to view it. Any information which was kept on the computer was also secure and password protected. Daily records were collected monthly and stored securely in the relevant care files.

● People were supported to be as independent as possible. A person said, "They help me with tasks I can't do by myself, when I need them to."

● Recently updated care records contained detailed descriptions of people's needs and abilities and how staff should support them to maintain their independence. For example, one care plan stated, '[Name of person] can wash their face, front of torso, arms and hands, but requires assistance to wash their back.' Another recently updated care plan stated, '[Name of person] will clean their own denture and teeth.' This then described the assistance the person required to do this task which included staff making provisions available to them.

● Staff told us that they considered people's independence when providing care. One staff member said, "I always encourage people to do what they can for themselves." Another staff member told us, "I will fill the sink up for the person and hand them the soap and flannel, so they can wash their face and hands themselves."

Responsive - Good

Responsive – this means we looked for evidence that the service met people's needs.

At the last inspection this key question was rated as Good. At this inspection this key question remained the same. This meant people's needs were met through good organisation and delivery. Planning personalised care to ensure people have choice and control and to meet their needs and preferences

● People told us they received personalised care and support specific to their needs and preferences.

● Some care plans included information in relation to people's likes and dislikes, personal preferences, health and social care needs, communication requirements and tasks they required support with during each visit. However, we found that some care plans contained minimal information in relation to specific areas such as, end of life care, likes and dislikes and details of personal abilities.

● Due to the consistency of the staffing team, positive feedback from people and relatives and the clear and detailed daily records it was evident that people were provided with appropriate care to meet their needs. Furthermore, the issues identified in relation to the care files were discussed with the registered manager and nominated individual who were able to provide us with evidence that these areas had been identified prior to the inspection and the service was in the process of updating people's care records to make them more person centred and easier to follow. They shared these up dated care plans with us which were detailed, clear and person centred.

● People and their relatives confirmed that staff knew them well and understood their needs. Comments included, "The carers have got to know [loved ones] likes and dislikes and the ways they like things done" and "they listen to me and do things how I want them to be done."

● Staff and the management team were responsive to people's changing needs. Staff reported any changes in people's needs to the office staff and management team; they also documented this within the person's care records held in their home. This meant that all staff who provided care to the person could be kept up to date with any changes or concerns, and this could be managed and monitored effectively to enable timely interventions.

● Staff confirmed if they were concerned about a deterioration in a person's health they would stay with the person and request medical support. People also supported this.

● People and their relatives told us any changes they required with their care calls were implemented without delay.

● People were empowered to make their own decisions and choices in relation to their care. Meeting people's communication needs Since 2016 onwards all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard (AIS). The standard was introduced to make sure people are given information in a way they can understand. The standard applies to all people with a disability, impairment or sensory loss and in some circumstances to their carers.

● People's communication needs were identified, recorded and highlighted in their care plans. This ensured Good 15 Say Care Limited Inspection report 26 March 2020 that staff were aware of the best way to talk with people and present information.

● The management team was aware of AIS. Documents could be given to people in a variety of formats, for example, easy read, large print and pictorial, if required. The service provided us with an example of a communication record for a person with a visual impairment which demonstrated the principles of AIS had been considered and followed. Improving care quality in response to complaints or concerns

● No complaints had been received by the service since the last inspection. However, there was a complaints policy in place and the registered manager was able to describe actions they would take if a complaint was received. Any complaints received would be acted upon immediately, investigated and actions taken where required.

● People were provided with information on how to complain. People and relatives confirmed they knew how to complain and were confident that if they raised a concern or complaint it would be acted on. A relative said, "There is a process to follow if I had a complaint, I have a copy of it, but I don't have any concerns at all." Another relative told us, "If I have a complaint I would go to [name of the registered manager]. I'm very confident they would listen and take action."

● Staff were aware of their duty to support people to make complaints or raise concerns. End of life care and support

● At the time of the inspection, one person supported by the service was receiving end of life care.

● The registered manager described how they supported people at the end of their life, which included working with healthcare professionals to ensure the person received effective care and supporting the person's loved ones. The registered manager said, "Our aim is to ensure people are comfortable, pain free and die with dignity." They added, "It is important to support the family and be there for them."

● Not all people had detailed individual end of life care plans in place, which gave clear information for staff about how to meet people's end of life goals and outcomes. However, a relative highly praised the end of life care they and their loved one had received and described how the needs of their loved one were met sensitively and effectively. The lack of recorded information in relation to people's specific end of life wishes was discussed with the registered manager, who agreed they would take action to ensure these were captured and recorded in the future.

● We saw 'thank you' cards from relatives in relation to the support provided to them and their loved one at the end of their life. Comments in one card included, '[Name of registered manager] you came to us like a guardian angel, you were professional and compassionate' and 'You all (staff) did a wonderful job and were always so patient and kind.' Supporting people to develop and maintain relationships to avoid social isolation; support to follow interests and to take part in activities that are socially and culturally relevant to them

● The staff were mindful of the risk of social isolation for people living in the community. The management team provided people with written information about local community groups and events and would offer people support to attend these if required.

● The service organised social events at key times of the year, for example, at Christmas a party was arranged for people.

Well Led - Requires Improvement

Well-Led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At the last inspection this key question was rated as Good. At this inspection this key question has now deteriorated to Requires Improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving care

● Systems to monitor the quality and safety of care delivered were in place however, improvements were needed to allow more robust processes to be implemented to allow timely actions to be taken. For example, the provider did not have a process in place to ensure safe recruitment practices were followed, some areas of staff training had not been updated in a timely way and there was not a process in place to review incidents and accidents, as a collective to identify themes and trends. Additionally, some completed care plans did not include detailed information required in relation to people's end of life wishes, did not contain detailed and consistent information and were difficult to follow. All of these issues were discussed with the registered manager and nominated individual who agreed to address these.

● There was a clear management structure in place which consisted of the directors, who was also the registered manager and nominated individual, care supervisors, care staff and office staff. Staff understood the role each person played within this structure.

● The registered manager and nominated individual, had a hands-on approach and demonstrated a clear passion for wanting to deliver high quality care to people in their own homes.

● The registered manager understood their responsibilities and had notified CQC about all incidents, safeguarding concerns and events that were required.

● Policies and procedures were in place to aid the smooth running of the service. For example, there were policies on equality and diversity, safeguarding, whistleblowing, complaints and infection control. Policies and procedures were also regularly shared with staff.

● There were quality assurance procedures in place to support continual improvement. These processes included the completion of audits, regular spot checks of staff and visits to people's homes to get face to face feedback on the quality of the service provided. Promoting a positive culture that is person-centred, open, inclusive and empowering, which achieves good outcomes for people

● All the people and relatives we spoke with praised the organisation and the running of the service. Words and comments used to describe all aspects of the service included, "Flawless", "excellent", "very good" and "exceptional." All people and relatives also said they would recommend the service to others. One person said, "I would recommend the service and have done so." A relative stated, 'We are very pleased with our choice of Say Care Limited. They have allowed mum to continue to live at home and would recommend this lovely group of people to anybody in similar circumstances.' Another relative said, "The team at Say Care Requires Improvement 17 Say Care Limited Inspection report 26 March 2020 have without fail been professional, empathetic & quick to react to each situation."

● People benefitted from receiving support from a supportive staff team who respected and valued each other.

● The management team encouraged an open culture and encouraged people and staff to contact them for support. Staff felt listened to and spoke very positively about the management and running of the service. They told us they felt fully supported by management and that they enjoyed a good working relationship with their colleagues. Staff comments included, "I have been treated very well by the managers and the service is very well organised", "The management are approachable and really responsive" and "It's the best service I have worked for, the managers and very considerate to both the clients and staff's needs."

● The previous performance rating was prominently displayed on the providers website. Engaging and involving people using the service, the public and staff, fully considering their equality characteristics

● People were encouraged to provide feedback and were supported to raise concerns if they were dissatisfied with the service. The directors of the service sought feedback from people and their families on an informal basis when they met with them in their own homes, during review meetings or via telephone or email contact. One person said, "They [registered manager] always contact and visit to see how things are going."

● People and relatives described the staff, the registered manager and nominated individual as approachable and all said they were confident that any feedback they gave about the service would be acted upon.

● Staff meetings were held regularly, and staff confirmed they were able to talk to the registered manager and nominated individual at any time. Staff told us that they felt involved within the service and were kept up to date with changes.

● There was an open-door policy. People and relatives all felt confident to contact the office to speak to staff about the care provided. Additionally, they all praised the responsiveness and approach of the staff within the office. How the provider understands and acts on the duty of candour, which is their legal responsibility to be open and honest with people when something goes wrong

● The provider had a duty of candour or policy that required staff to act in an open and transparent way when accidents occurred.

● The registered manager had a good understanding of their duty of candour requirements and was able to demonstrate that this would be followed where required.

● Staff knew how to whistle-blow and how to raise concerns with the local authority and with CQC if they felt they were not being listened to or their concerns acted upon. Working in partnership with others

● The service worked well and in collaboration with all relevant agencies, including health and social care professionals. This helped to ensure there was joined-up care provision.

● Staff liaised with health and social professionals to ensure people's health and social care needs could be effectively met. This enabled people to enjoy healthier lives in their own home.

● Where people required any equipment, the service worked with health and social care professionals to ensure this was in place promptly.