Nation Care Agency is a domiciliary care service providing personal care and support to people living in their own homes. At the time of the inspection the service provided support for approximately 65 adults, which included a majority of older people and a few younger adults. The assessment started on 30 September 2024 and ended on 15 October 2024. We visited the provider’s office on the 2 October 2024. We carried out telephone interviews with people receiving support and relatives on 15 October 2024. We received feedback from staff via email between 3 October 2024 and 15 October 2024. We assessed all the quality statements in the key questions of safe, effective, responsive and well led but only 1 quality statement in caring. We found areas of good practice. The score for caring has been combined with scores based on the key question rating from the last inspection. Though the assessment of these five quality statements indicated good practice since the last inspection, our overall rating remains good. The provider had made improvements to the monitoring of when visit times occurred to ensure they were at the agreed time. People were assessed to ensure they could make decisions about their care they received and to ensure it was provided in the least restrictive manner possible. The provider had made improvements to the management of complaints, and they were responded to in a timely manner. People’s risks were identified, and risk management plans were developed. In response to the concerns identified following the previous inspection the provider had made improvements to their quality assurance processes to help them to make improvements when required. People’s medicines were managed safely and there were procedures for infection prevention and control. People were involved in the development and review of their care plans and were asked for feedback on the care they received.
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Nation Care Agency was rated Inadequate overall following a November 2021 inspection, with Warning Notices issued for breaches of regulations covering safe care and treatment, good governance, and staffing. Widespread failures were found across risk management, medicines administration, visit scheduling, staff training, care planning, mental capacity assessment, complaints handling, and governance, resulting in the service being placed in special measures.
Concerns (13)
criticalCare planning: “Care plans were not written in a person-centred manner which identified the person's wishes in relation to how they wanted their care provided.”
criticalMedication management: “The provider did not have a PRN protocol in place to provide care workers with guidance on when they should administer these medicines.”
criticalMissed or late visits: “120 care visits had been scheduled for 31 care workers which overlapped a visit for another person... visits occurring over one hour later or earlier than planned.”
criticalStaffing levels: “46 care visits had been allocated to 23 care workers without travel time for the next visit so one visit ended at the same time the next visit started.”
criticalStaff training: “The provider could not demonstrate the care workers had completed the additional 12 training courses they identified as mandatory which included safeguarding adults and health and safety.”
criticalGovernance: “The provider carried out an audit of MAR charts... The audits were not robust enough as they indicated there were no issues, but we found a range of concerns.”
criticalIncident learning: “Records for three safeguarding concerns were reviewed and we saw that there was limited information recorded about what happened with no lessons identified.”
criticalConsent / capacity: “The provider did not always undertake mental capacity assessments where people might not have the capacity to consent to their care, in line with the MCA.”
moderateComplaints handling: “Complaints records showed that outcomes following complaints investigations and measures to prevent similar concerns were not always identified.”
moderatePerson-centred care: “The daily records of care provided during each visit were task focused and did not reflect the experiences of the person receiving support.”
moderateEnd-of-life care: “People's wishes in relation to their end of life care were not recorded as part of their care plan.”
moderateCommunication with families: “The care plan for one person indicated they lived with a hearing impairment and used lipreading... The person's care plan had not been updated to provide care workers with guidance.”
moderateRecord keeping: “The provider informed us they supported eight people with their medicines, but the local authority confirmed that at the time of the inspection there were 22 people being supported.”
Strengths
· Safe recruitment process in place with full employment history, two references and criminal record checks for new staff.
· Care workers had access to appropriate PPE including gloves and face masks, confirmed by people and relatives.
· Provider worked in partnership with the local authority and maintained regular meetings to discuss service improvements.
· Supervision records indicated supervisions had taken place as required, including one-to-one meetings, appraisals, spot checks and group supervisions.
· Care workers demonstrated understanding of safeguarding principles and MCA.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and managementInadequate
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Learning lessons when things go wrongInadequate
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careGood
responsive: Meeting people's communication needsRequires improvement
responsive: Planning personalised care to ensure people have choice and controlRequires improvement
responsive: End of life care and supportRequires improvement
responsive: Improving care quality in response to complaints or concernsRequires improvement
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
well-led: Continuous learning and improving care; quality assurance processesInadequate
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
Nation Care Agency improved from Inadequate to Requires Improvement overall, exiting Special Measures, but remained in breach of four regulations covering staffing deployment, consent/MCA, complaints handling, and governance. While caring practices were rated Good and medicines management had improved, persistent failures in visit punctuality, quality assurance robustness, and complaint investigation effectiveness continued to place people at risk.
Concerns (8)
criticalMissed or late visits: “49 care workers had at least one visit which started outside of the one-hour window which was 17% of all visits that week.”
criticalConsent / capacity: “The provider's processes in relation to assessing a person's capacity to make decisions about their care did not always follow the principles of the MCA.”
criticalComplaints handling: “The provider did not always consider the issue of the complaint as part of their investigation which meant the investigation was not always effective at identifying preventative measures.”
criticalGovernance: “The provider did not have effective and robust quality assurance processes to monitor, assess and improve the quality of services people received.”
criticalStaffing levels: “The provider did not ensure sufficient suitably qualified, competent, skilled and experienced staff were deployed to meet people's support needs.”
moderateIncident learning: “The provider could not demonstrate that they had investigated the concern, analysed the cause and identified the actions required to prevent a similar concern.”
moderateCare planning: “There was no risk management plan for when the person was supported to take part in activities outside of their home.”
moderateRecord keeping: “The audits for the May 2022 included the same issues that were identified in the April 2022... the reason for these errors was not identified so preventative measures could be taken.”
Strengths
· Medicines were managed appropriately with completed MAR charts and PRN guidance in place.
· Care workers completed mandatory training including Care Certificate, basic life support, and infection control.
· Care plans identified communication needs, cultural preferences, and end of life care wishes.
· People and relatives felt safe and reported care workers treated them with dignity, kindness and respect.
· Robust recruitment processes in place including DBS checks, references and right-to-work verification.
Quality-Statement breakdown (21)
safe: Staffing and recruitmentRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Systems and processes to safeguard people from the risk of abuseGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceGood