Bryce Care (Domiciliary Care Service)

Care and Social Services Inspectorate Wales
Care Standards Act 2000
Inspection Report
Bryce Care (Domiciliary Care Service)
2 Main Road
Dyffryn Cellwen
Neath
SA10 9HR
Type of Inspection – Baseline
Dates of inspection – 04/02/15, 12/02/15, 16/02/15, 16/03/15
Date of publication – 20/04/15
Welsh Government © Crown copyright 2015.
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Version 1.1 07/2012
Summary
About the service
Bryce Care Ltd is a domiciliary care agency which is registered by us, Care and Social
Services Inspectorate Wales (CSSIW) to provide domiciliary and personal care to adults
over the age of 18 years. The main office is situated in Duffryn Cellwen, in the Dulais
Valley in South Wales. The agency has undergone many changes over the past few
months, having expanded and increased its staff numbers and geographical margins to
include areas of Powys. At the present time, the Duffryn Cellwen office provides services
to people living in five supported living houses owned by Catreifu Cwm, a local property
company. In addition Bryce Care provides domiciliary care services as part of a
subcontracted arrangement from its subsidiary company Alpha Home Care Services,
which is commissioned by Powys County Council.
The Responsible Individuals for the company are Colin Bryce and Mary Bryce, and the
Registered Manager is Stuart Bryce-Jones. There are two proposed registered managers
currently undergoing the registration process, one will develop services in the Dulais
Valley office, and the other proposed manager will develop services from a new Brecon
office which is not yet registered for use. The current Registered Manager was not
present on the days of the inspection visits.
What type of inspection was carried out?
A scheduled, unannounced, baseline inspection was carried out on this occasion which
looked at all themes relevant to domiciliary care agencies in Wales: the Quality of Life for
the people using the service, the Quality of staffing and the Quality of Leadership and
Management. In addition we have received a number of concerns relating to service
delivery in the Powys area. The inspection was carried out by one inspector, over four
days using the following methodology:
Four visits to the Dulais Valley offices
Discussions with both proposed registered managers
Telephone and one to one discussions with staff chosen randomly from staff
records held in the offices
Visits to people’s homes: We visited three people in their homes who used the
service, and had face to face discussions with one relative. Two other people either
cancelled our appointment or did not return our call when contacted by telephone
on three occasions.
Telephone conversations: We spoke by telephone to three people who used the
service and two relatives.
Examination of a range of records pertaining to staff
Examination of a range of records pertaining to the people being attended by Bryce
Care Ltd
Perusal of documentation such as Regulation 26 forms which are completed when
an untoward event occurs, such as a missed call.
What does the service do well?
There were no areas of exceptional practice identified at this inspection.
What has improved since the last inspection?
The last inspection was prior to both the expansion of the company (which has been
rapid), and the intention to operate two offices with two registered managers in different
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areas resulting from an extension of its services. Therefore, due to the many differences
found since the last inspection, we could not identify any improvements on this occasion
which would have been comparable to the previous visit by CSSIW.
What needs to be done to improve the service?
We (CSSIW) notified the provider that the service is not compliant with Regulation 4 (b),
(c), (d). This is because the Statement of Purpose did not meet the requirements of
Schedule 1 of the Domiciliary Care Agencies (Wales) Regulations 2004. Our findings
were that the content had unsuitable wording, and did not reflect the extended services
provided. A non compliance notice has been issued.
We notified the provider that the service is non compliant with Regulation 26 of the
Domiciliary Care Agencies (Wales) Regulations 2004. This is because we have evidenced
that not all incidents have been reported to CSSIW by forwarding a notification. A non
compliance notice has been issued.
We notified the provider that the service is non compliant with Regulation 13 (a) & (b) of
the Domiciliary Care Agencies (Wales) Regulations 2004. Because of the high number of
missed calls we could not evidence that the service ensures the safety of service users
and safeguards them against neglect. A non compliance notice has been issued
We notified the provider that the service is not compliant with Regulation 14 (3) of the
Domiciliary Care Agencies (Wales) Regulations 2004. Because of the number of missed
calls people cannot be confident that the agency will meets people’s needs as specified in
the service delivery plan. A non compliance notice has been issued.
We notified the provider that the service is not compliant with Regulation 14 (1) of the
Domiciliary Care Agencies (Wales) Regulations 2004. This is because we looked at five
records of people who used the service and found that the documentation that was being
used across the organisation consisted of a ‘multi-tasking document’ which was not person
centred, or in line with the Local Authority plan of care. In addition we found that the
documentation viewed was generally entitled ‘Alphacare’, the other company owned by
Bryce Care Ltd. It did not appear that any effort had been made to replace or update the
documentation in December 2014, when Bryce Care Ltd had taken over the calls. A non
compliance notice has been issued.
We notified the provider that the service is not compliant with Regulation 16 (1) (c) of the
Domiciliary Care Agencies (Wales) Regulations 2004. This is because we did not see
evidence that staff with conditions such as diabetes had appropriate risk assessments in
place, with regards to their health. The company should urgently review the staff members
with conditions that may require attention during the working day. A non compliance notice
has been issued
We notified the provider that the service is not compliant with Regulation 16 (2) (a) of the
Domiciliary Care Agencies (Wales) Regulations 2004. This is because we were informed
that staff did not always receive training prior to attending those with specialised conditions
or equipment, such as Percutaneous Endoscopic Gastrostomy (PEG) feeding. A non
compliance notice has been issued
We notified the provider that the service is non compliant with Regulation 16(4) of the
Domiciliary Care Agencies (Wales) Regulations 2004. This is because we could not
evidence that all staff had had the opportunity to attend one to one meetings with their line
manager. A non compliance notice has been issued.
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We notified the provider that the service is non compliant with Regulation 23 (1), (2), (3) of
the Domiciliary Care Agencies (Wales) Regulations 2004. This is because there was no
quality assurance report available. A non compliance notice has been issued.
We notified the proposed registered managers that:
The computer system in place did not appear to be suitable for the size of the company.
We saw no evidence of IT systems in place which could support the management in
tracking or sharing of documentation. When the Brecon office is open this may prove
problematic, as unless there is a seamless flow of information between the two offices,
there is a risk of a two tier service, where information is slower in one area than another.
Staff rotas in the Brecon area appeared to be unfairly distributed. Staff from surrounding
areas often have to make trips of up to 60 miles to the Brecon office and back to receive
their rotas at their own expense. In addition we were informed that rotas are often late and
only received the day before someone is expected to carry out a visit.
We noted that the proposed manager for the Duffryn Cellwen/Neath office was also acting
as a telephone receptionist. We noted over the visits we made, that she answered the
telephone on numerous occasions, passing the calls on to other people - two calls only
were for that office during one of our visits, and we discussed the impact that the phone
calls were having on her managerial duties. We recommend that a clearly defined job
description should be made for managerial staff, and suitable arrangements made to cover
telephone calls.
Supervision records were being stored on an open shelf in the office of the proposed
registered manager for the Duffryn Cellwen offices. We discussed with her that this was
unacceptable due to the potential for unauthorised access. The records must be stored in
a manner to ensure confidentiality. In addition, the supervision records were disorganised,
not in date order, and we noted gaps in the time frame in some of the files viewed. At a
subsequent visit we noted that the supervision records had been moved to a locked filing
cabinet, but we did not examine them to see if they had been put in order. This may be a
focus for future inspections.
Three randomly chosen staff records examined were broadly in line with Schedule 3 of the
Domiciliary Care Agencies (Wales) Regulations, 2004, in terms of recruitment. However,
we found that in one staff record there were references that were not signed, and there
was no evidence of induction. The staff member had been with the organisation for some
years. As there was no evidence of complaint or disciplinary action taken in the years
worked there, we discussed with the proposed registered manager that a written risk
assessment should be placed in this file with an associated explanation as to why the
references were not acceptable. We could not identify a documented induction period. We
recommend that an audit of staff records should be carried out at the earliest opportunity.
Other documentation, such as job descriptions, and policies and procedures, were clearly
the same format and content as previously, but had ‘Bryce Care Ltd’ as headings. We
were informed by the proposed registered manager for the Neath/Duffryn Cellwen office
that the policies had been updated but were ‘awaiting approval’ from one of the company
directors. We recommend that urgent attention is given to the review and updating of
these documents, as those randomly viewed by us did not appear to have been altered,
but just given ‘Bryce Care Ltd’ headings and a date for review.
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Quality of life
Overall, the agency had a difficult period when through their subsidiary company which
has the Powys County Council contract, they took over the Powys Local Authority area
hours from other agencies in Brecon in December, 2014. We found that people were
generally satisfied with the “hands on” care given, but not with the many missed calls
and different staff members who were sent to them by the agency from the start of the
Powys service to the time of this inspection. This is because we visited or spoke by
telephone to people who used the service or relatives or their representatives who had
made formal complaints. All those spoken with expressed their concerns that although
the initial changeover to Bryce Care Ltd in December 2014 from their previous care
agencies had been fairly traumatic, the service had for a very short period ‘settled’, and
‘become more organised’, only to revert back to the initial ‘shambles’ within a short time
period. This was characterised by missed calls, late calls, and multiple, unknown staff
attending in some instances. One person expressed that they had felt unsafe as so
many people had knowledge of the key-safe door number to enter the premises.
Because of the serious impact on individual service users some of the concerns
received by or notified to CSSIW have resulted in vulnerable adult safeguarding
referrals. CSSIW has attended a significant amount of strategy meetings as a result. As
harm or risk of harm has been attributable to missed calls we consider it necessary to
issue a non compliance notice for failure to ensure the safety and protection of service
users. Bryce Care are non compliant with Regulation 13 (a) and (b). As a result of
missed calls some people using the service have not always received their medication,
meals and personal care and therefore have not been protected from neglect.
People could be confident however that the quality of the attending staff and the ‘hands
on care’ they received was generally good. This is because people with whom we spoke
informed us that attending staff were always neatly dressed in identifiable uniform,
carried identification, and were polite and well-mannered at all times. We were further
informed that for personal care, staff always had a supply of personal protective
equipment such as disposable gloves, aprons and wipes, which they used appropriately
and observed good infection control practises.
Our inspection demonstrated that there are areas of concern which the registered
person needs to address to ensure people using the service receive reliable, good
quality care which is flexible to meet their individual needs. Bryce Care are non
compliant with Regulation 14 (3) of The Domiciliary Care Agencies (Wales) Regulations
2004. This is because of the high number of missed calls which leaves service users
potentially vulnerable and at risk. Due to missed calls Bryce Home Care are unable to
ensure that the personal care which the agency arranges meets the service user’s
needs specified in the service delivery plan. It has been evidenced at safeguarding
meetings that due to missed calls people have not received meals, medication and
personal care. A non compliance notice has been issued in this regard.
Bryce Care are non compliant with Regulation 14 (1) of The Domiciliary Care Agencies
(Wales) Regulations 2004. People could not be confident that the format used to record
and plan their care was consistent or accurate. This is because we examined the
records of five of the people who used the service. All the documentation viewed, apart
from the supported living home care service, was that of the previous care provider, and
all were ‘multi-tasking’ documents and did not appear to be person-centred, or have an
outcome focus. In addition, the documentation viewed had the previous provider’s name
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crossed out and ‘Bryce Care’ hand written in its place. There was, however, evidence of
review in the records examined. Even the daily records in people’s homes were the
previous provider’s forms which was not only confusing, but misleading, and did not give
the impression of efficiency, clarity, or control. We found food, urinary and bowel charts
in records, that were not completed and we recommend that urgent attention is paid to
the review of all documentation in order to make it corporate, appropriate, person
centred and outcome focussed.
Both proposed managers expressed their commitment to improving the service over the
next few months. They agreed to address the issues discussed and carry out total
review and update of the documentation in order to achieve a positive outcome, and
secure the continuity of care and safety and wellbeing for users of the service.
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Quality of staffing
Overall, we found that the seven staff spoken with were committed to those they cared
for, and were kind and caring in their approach to attending people in their own homes.
This is because their attitude to their work was enthusiastic, and they spoke about the
service they provided with dignity and respect for those who required personal care.
Most staff we spoke with, when asked how they felt about the quality of the service
immediately started with the impact the changeover had had on the ‘client’, rather than
on themselves.
The staff spoken with mostly expressed that they had initial anxieties when the company
took over the Powys calls. A general lack of organisation and poor communication was
spoken of but things had improved since January 2015; staff were in the process of
signing new contracts. The company were phasing out ‘zero hour’ contracts and
ensuring that fixed hour contracts only were offered. This was confirmed by all the staff
spoken with, as they had recently signed their new contracts and stated that they were
satisfied with the terms and conditions.
We examined the records of three of the staff members and found them to be broadly in
line with Schedule 3 of the Domiciliary Care Agencies 2004, (Wales) Regulations, as
they all had photos, references, and evidence of criminal record activity. However, we
noted that in one record, there were references that were not signed, and there was no
evidence of induction. The staff member had been with the organisation for some years.
As there was no evidence of complaint or disciplinary action taken during their
employment we discussed with the proposed registered manager that a written risk
assessment should be placed in this file with an associated explanation as to why the
references were not acceptable. We noted that there was no documented induction. We
recommend that an audit of staff records should be carried out at the earliest
opportunity.
We looked at staff files and noted that supervision was not regular or consistent in all
geographical areas. Bryce Care must develop a system to audit supervision to ensure
they take place in accordance with Regulation 16 (4) of the Domiciliary Care Agencies
(Wales) Regulations 2004 and that this is sustained on a regular basis. Although team
meetings are taking place people are not always given the opportunity to have one to
one sessions. A non compliance notice has been issued in this regard.
Most of the staff concerns expressed were commonly held:
We were informed that in one area a local pick up point for rotas and personal
protective equipment such as disposable gloves and aprons, had been promised
initially. Staff were told that there would be a senior person available to discuss
any issues. In some instances they now had to make up to a 60 miles round trip,
to the Brecon office (which was not yet registered at the time of our inspection)
and there not always a senior person available. We were informed by staff that
they were not paid for this journey.
The rotas were often not available until hours from the next due rota. One person
described leaving a late call, which started at 10pm, and found on returning home
that the first call the next day was at 6.15 am. This amounts to less than the
minimum period for rest between shifts under the European Working Time
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Directive which is 11 consecutive hours.
Some of the supervisors were reported as being not as approachable as others,
although all staff had good experiences with the proposed managers. Several
staff stated that the supervisors spoke to them in an “…abrupt…”, “bit nasty…”
“…offhand…” manner, making them feel coerced into taking on extra shifts even if
they did not want to work. In three of the conversations held, we were informed
that staff had been told that they would be reported to “POVA” (safeguarding) if
they did not agree to attend extra calls.
Bryce Care are non compliant with Regulation 16 (1) c of The Domiciliary Care
Agencies (Wales) Regulations 2004. There did not appear to be risk assessments
in place around the health of some staff members. Those with conditions such as
diabetes did not appear to have phased time in place to check blood sugars, eat,
or had even been asked about their condition, and any special arrangements
necessary. This must be addressed at the earliest opportunity. A non compliance
notice has been issued.
Several stated that they were “…contacted a lot…” Three people expressed the
view that ‘…rota’s sometimes change at a moment’s notice…’ and that this
needed to be ‘…sorted out, for everyone’s sake.”
People could not be confident that staff training had been audited and reviewed to
ensure that all training for all staff was current and relevant. Most training was provided
by Bryce Care Ltd Training Company. Bryce Care are non compliant with Regulation 16
(2)a of The Domiciliary Care Agencies (Wales) Regulations 2004 because we were
informed by one staff member that in their experience training in specialised areas had
not been forthcoming. They had to learn from a colleague in an area requiring
specialised knowledge. A non compliance notice has been issued. It is essential that the
company look into this, and ensure that untrained staff do not attend to anyone requiring
any specialised attention, such as moving and handling and use of specialised
equipment until they have received training given by appropriate professionals to ensure
the health and safety of both the person using the service and the staff member.
Percutaneous Endoscopic Gastronomy (PEG) feeding, and colostomy care, are further
examples.
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Quality of leadership and management
Overall, we found that the agency’s leadership and management arrangements were not
robust and it was lacking in communication. This is because we spoke with staff and
people using the service, and examined some of the documentation which is required of
a domiciliary care agency. We found shortcomings in areas such as client
documentation, notification of untoward incidents such as missed or late calls, and
review and updating of policies and procedures. There were also staff issues such as
rotas, travelling time and contracts.
In addition, we initially noted that the Statement of Purpose did not meet the
requirements of Schedule 1 and Regulation 4 (b) (c) (d) of the Domiciliary Care
Agencies (Wales) Regulations 2004 as it did not reflect the service offered and required
total updating and review. Whilst we acknowledged that during our fourth visit this had
much improved, it was still not suitable for use and a non compliance notice has been
issued in this regard. The complaints procedure and policies and procedures generally
were similarly in need of attention.
The company had recently experienced a rapid expansion having taken over calls in the
Powys area from another care agency in December 2014. Some staff who wished to
remain as care workers in those areas transferred over from the previous care agency,
to Bryce Care Ltd. Staff and people spoken with described the first month of the new
contract as a ‘shambles’. It would appear that the transition from a small, local
company, to a larger entity had occurred before the necessary business infrastructure
such as ICT, relevant training and human resources systems had been put in place.
One significant area for concern is evident staff shortages in the Powys area. We were
informed that there is an ongoing recruitment drive. When fully staffed Bryce Care Ltd is
confident that it will be able to provide consistency and continuity for people who use the
service and staff members. Clearly, a lack of consistency and continuity has impacted
negatively on a number of service users with implications for their safety and wellbeing
and the need to increase staffing is vital to improve outcomes for people receiving this
service. This will continue to be monitored by CSSIW.
Efforts are being made to address the current lack of organisation and to reduce the
level of complaints received such as over the Christmas period. This is because two
new, proposed registered managers have been employed both of whom are undergoing
the CSSIW registration process. Both hold the relevant management qualification and
are registered with the Care Council for Wales which is a pre-requisite of CSSIW
registration. We understand that in the case of one manager the registration decision is
imminent. The other proposed manager had worked for Bryce Care Ltd for a short
period only at the time of our inspection. We were informed that the intention is for one
manager to work from the Duffryn Cellwen/Neath office, which currently is responsible
for the service supplied to five supported living houses, but which also hopes to expand
domiciliary care across Neath and the surrounding valleys. The other manager will
eventually run the Brecon office, once registration is completed and also expand that
service.
At the time of our visit, an independent financial auditor was carrying out an analysis of
the company finances, in line with Powys Local Authority requirements for agencies
providing services in their area. We spoke with the Financial Services Manager, who
informed us that all finance for clients in the supported living homes are monitored and
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audited by each relevant council. We did not request audited accounts on this occasion
as we will await the outcome of the current financial assessment. This may be a focus
for our next inspection.
We have been made aware that there has been a large number of late and missed calls
for which we have not been notified by the agency in line with Regulation 26 of the
Domiciliary Care Agencies (Wales) Regulations 2004 notification procedures. A non
compliance notice has been issued with this regard. On occasions we have been
contacted by people using the service, their relatives and or representatives, and Powys
Local Authority to inform us of these failings in the service. We were informed that a
new call monitoring system should be available and in place in the near future. This is
being provided by Powys Local Authority and they along with Bryce Care Ltd will have
instant access to the calls being undertaken. In addition, we spoke with the proposed
manager for the Powys area who indicated that she is working to ensure that this does
not reoccur, and had been the result of a particular ‘run’ where confusion arose over
responsibilities. She acknowledged that this was unacceptable and is working on a
computerised log which will list complaints/concerns, Regulation 26 forms, and
safeguarding referrals, for easy access and tracking. The manager indicated that a
paperless system was also being sought, but until the basics were in place, any new
computerised system would have to wait.
People cannot be confident that they are always being respected and listened to. This is
because although some of the people we visited indicated that they were generally
satisfied with the response from any dealings with the management, others told us that
they had been informed by one of the directors, when no staff had called, that “…no-one
is coming…” and that their relative’s health was “…not my responsibility…” . Other
people who had rung the out of hours service following a missed call had been informed
that “…the carer’s have finished now…”.
However, Bryce Care Ltd are trying to address this by undertaking spot checks and
telephone calls to ensure that staff had attended on time, and that the service was being
delivered in accordance with Local Authority plans. This was confirmed by some of the
staff and people spoken with during the inspection.
Bryce Care were unable to show us a copy of their quality assurance report as required
by Regulation 23 of the Domiciliary Care Agencies (Wales) Regulations 2004. We were
initially informed that it was in the process of being written, and we were shown a
document that would be presented as a quality assurance report but it was blank.
We also found that there was no evidence that there was sufficient data collated or a
suitable system in place to formulate a report. The outcome for the people using the
service was that the agency was not measuring quality indicators or targets to effectively
plan or change the service in an informed manner which was person centred and
outcome focussed. A non compliance notice has been issued
People cannot be confident that the organisational management were communicating
well, as we were concerned that the proposed manager for the Duffryn Cellwen/Neath
office did not appear to be fully informed. We found from discussions with the two
proposed managers that a new call monitoring system was being introduced for the
Powys area. Only the one proposed manager for that area was attending the training for
this despite the fact that the agency was currently operating from the one office in
Duffryn Cellwen/Neath. She was also answering the phone for all calls to the company,
generally, and during our visits answered numerous calls for other people in the
organisation. She was constantly interrupted by the phone and we discussed with her
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the impact this has on her managerial duties.
Although the company have a lot of work ahead in terms of their office and business
systems, the arrangements currently being made, appear to be making inroads to
addressing some of the earlier encountered problems and complaints.
We acknowledge that the expansion into Powys, in December 2014, was rapid. It
appears not to have been part of a planned service development but rather as a
consequence of the subsidiary company Alpha Home Care Services awarding of the
Powys County Council contract to provide domiciliary care services as a result of its
retendering exercise in 2014.
We were informed by several people that the
“…expansion was a shambles…”, and we consider, from our inspection, that poor
communication, organisation, and system errors led to staff retention problems and
shortfalls in the service which have been ongoing and impacting negatively on some of
the people using the service.
An early inspection in the new inspection year is recommended to ensure that the
measures being put in place come to fruition, and that regulations and standards are met
on all levels.
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Quality of environment
This theme is not relevant to Domiciliary Care Agencies.
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How we inspect and report on services We conduct two types of inspection;
baseline and focussed. Both consider the experience of people using services.
Baseline inspections assess whether the registration of a service is justified and
whether the conditions of registration are appropriate. For most services, we carry out
these inspections every three years. Exceptions are registered child minders, out of
school care, sessional care, crèches and open access provision, which are every four
years.
At these inspections we check whether the service has a clear, effective Statement of
Purpose and whether the service delivers on the commitments set out in its Statement
of Purpose. In assessing whether registration is justified inspectors check that the
service can demonstrate a history of compliance with regulations.
Focussed inspections consider the experience of people using services and we will
look at compliance with regulations when poor outcomes for people using services are
identified. We carry out these inspections in between baseline inspections. Focussed
inspections will always consider the quality of life of people using services and may
look at other areas.
Baseline and focussed inspections may be scheduled or carried out in response to
concerns.
Inspectors use a variety of methods to gather information during inspections. These may
include;
Talking with people who use services and their representatives
Talking to staff and the manager
Looking at documentation
Observation of staff interactions with people and of the environment
Comments made within questionnaires returned from people who use services, staff
and health and social care professionals
We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of
service are referred to within our inspection reports.
Further information about what we do can be found in our leaflet ‘Improving Care and
Social Services in Wales’. You can download this from our website, Improving Care and
Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW
regional office.
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Care and Social Services Inspectorate Wales
Care Standards Act 2000
Non Compliance Notice
Domiciliary care agency
This notice sets out where your service is not compliant with the regulations. You, as the
registered person, are required to take action to ensure compliance is achieved in the
timescales specified.
The issuing of this notice is a serious matter. Failure to achieve compliance will
result in CSSIW taking action in line with its enforcement policy.
Further advice and information is available on CSSIW’s website
www.cssiw.org.uk
Bryce Care (Domiciliary Care Service)
2 Main Road
Dyffryn Cellwen
Neath
SA10 9HR
Date of publication – 20/04/15
Welsh Government © Crown copyright 2014.
You may use and re-use the information featured in this publication (not including logos) free of charge in
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You must reproduce our material accurately and not use it in a misleading context.
Domiciliary Care (GIRPTE.0001356766)
Version 8.1 July 2012
Care and Social Services Inspectorate Wales
South West Wales
Government Buildings
Picton Terrace
Carmarthen
Carmarthenshire
SA31 3BT
0300 790 0126
0872 437 7303
Name of agency:
Bryce Care (Domiciliary Care Service)
Contact telephone number:
01639 700194
Registered provider:
Bryce Care Ltd
Registered manager:
Stuart Bryce
Category:
Agency>200hrs
Dates of this inspection from:
04/02/15 to
16/03/15
Dates of other relevant contact since
last report:
Date of previous report publication :
Other regions contributing to this
report:
Ruth Jones
Domiciliary Care (GIRPTE.0001356766)
Version 8.1 July 2012
Quality of life
Non compliance identified at this inspection and action to be taken
Action to be taken
Timescale for
completion
The service is not compliant with 17/04/15
Regulation 13 (a) & (b). Alpha Home
Care must take action to ensure the
safety of service users. Inform CSSIW
of action taken
Regulation number
13(a)
13(b)
Regulation 13 (a) and (b) The service is non compliant with Regulation 13 (a) & (b) and this is because of the
number of missed calls and the potential risk of neglect to people who use the service.
CSSIW have attended a large number of strategy meetings regarding missed calls. It has
been noted in the safeguarding referrals that some people have not had their needs met
with regard to medication, nutrition and personal care in particular continence needs. This
leaves them vulnerable and potentially at risk.
Bryce Care must take action to ensure that the agency is conducts personal care provided
to ensure the safety of service users and safeguard against abuse and neglect.
The impact on people using the service is that they are being potentially put at risk as their
individual care needs are not being met
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Domiciliary Care (GIRPTE.0001356766)
Version 8.1 July 2012
Quality of staffing
Non compliance identified at this inspection and action to be taken
Action to be taken
Timescale for
completion
The Registered Persons must carry out 17/04/15
and record in each individual staff
record a risk assessment for those with
conditions requiring time allowances for
attending to health issues.
CSSIW to be informed of action taken.
The Registered Persons must ensure 17/04/15
that staff receive specific training for
any
duties
involving
specialist
equipment or tasks they are to perform
by appropriately qualified people.
CSSIW to be informed of action taken.
Regulation number
16(1)(c )
16(2)(a)
Regulation 16 (1) (c) –
This is because we did not see evidence that staff with conditions such as diabetes had
appropriate risk assessments in place.
This meant that there was a potential for staff to experience symptoms which could
adversely affect their performance.
The impact on the people using the service could be that staff might be unable to carry out
their agreed care placing them at potential risk.
Regulation 16 (2) (a) –
This is because we found no evidence that staff had received any specific training when
attending to people with conditions which required specialised equipment or techniques.
We also found no evidence that appropriate health care professionals had carried out
training in procedures requiring their specialised knowledge.
The impact for the people using the service was that they may be at risk by receiving a
service that has not been appropriately provided for in terms of staff training.
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Domiciliary Care (GIRPTE.0001356766)
Version 8.1 July 2012
Quality of leadership and management
Non compliance identified at this inspection and action to be taken
Action to be taken
Timescale for
completion
The Registered Persons must ensure 17/04/15
that the Statement of Purpose complies
with Schedule 1 of the Domiciliary Care
Agencies (Wales) Regulations 2004.
CSSIW to be notified of action taken.
The Registered Persons must ensure 17/04/15
that the documentation in use is person
centred and outcome focussed and in
line with the Local Authority plan.
CSSIW to be notified of action taken.
The Registered Persons must ensure 17/04/15
that they carry out a Quality Assurance
survey annually, and produce a report
which is circulated to CSSIW and made
available on request to interested
parties.
The service is non compliant with 17/04/15
Regulation 26 (1). Bryce Care must
take action to ensure that they
complete a Regulation 26 notification
and forward to CSSIW when an
incident occurs. Inform CSSIW of the
action taken
The service is non compliant with 17/04/15
Regulation 16 (4). This is because we
looked at staff files and noted that
supervision was not regular or
consistent. Inform CSSIW of action
taken.
The service is non compliant with 17/04/15
regulation 14 (3). Bryce Care must take
action to ensure all identified needs are
met as specified in the service delivery
plan. Inform CSSIW of action taken.
Regulation number
4(1)(b)
4(1)(c)
4(1)(d)
14 (1)(a)
23 (1)
23 (2) (a)
23 (3) (a)
26(1)
16(4)
14 (3)
The service is not compliant with Regulation 4 (b), (c), (d)
This is because the Statement of Purpose did not meet the requirements of Schedule 1 of
the Domiciliary Care Agencies (Wales) Regulations 2004.
Our findings were that the content had unsuitable wording, and did not reflect the service
offered.
The impact on the people using the service is that they could be misled and misinformed
by this document.
The service is not compliant with Regulation 6 (1), (a), (b), and (2)
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Domiciliary Care (GIRPTE.0001356766)
Version 8.1 July 2012
This is because the Statement of Purpose was not current and had not been revised.
We found that the last date on the Statement of Purpose was 2011.
We had not been notified of any update or revision.
The outcome for the people using the service is that they may be receiving a service that
is not current and relevant to their needs based on information that is not current.
The service is not compliant with Regulation 14 (1) a
This is because we looked at five records of people who used the service and found that
the documentation that was being used across the organisation consisted of a ‘multitasking document’ which was not person centred, or in line with the Local Authority plan of
care.
In addition we found that the documentation viewed was generally entitled ‘Alphacare’, the
other company owned by Bryce Care Ltd. It did not appear that any effort had been made
to replace or update the documentation in December 2014, when Bryce Care Ltd had
taken over the calls.
The outcome for the people using the service was that the care being given either did not
entirely reflect the Local Authority plan, or lacked clarity, and was not outcome focused.
The service is not compliant with Regulation 23 (1), (2), (3)
There was no quality assurance report available.
This is because we were initially informed that it was in the process of being written, and
we were shown a document that would be presented as a quality assurance report but it
was blank.
We also found that there was no evidence that there was sufficient data collated or a
suitable system in place to formulate a report.
The outcome for the people using the service was that the agency was not measuring
quality indicators or targets to effectively plan or change the service in an informed manner
which was person centred and outcome focussed.
The service is non compliant with Regulation 16 (4)This is because staff are not appropriately supervised. We looked at staff records on
December 15 2014 and noted that supervision was not regular or consistent.
The evidence showed that the manager had not developed a system to audit supervision
to ensure it takes place and that it is sustained on a regular basis. The Registered
Manager must ensure that supervision is undertaken to ensure that people receive care
from properly supervised staff. Bryce Care to inform us when a robust system is in place
and supervisions have taken place.
The impact on people using the service is that they are potentially put at risk by staff who
are not supported, guided or monitored in their role.
The service is not compliant with Regulation 14(3)This is because of the large number of missed calls which impacts the delivery of care as
specified in the service delivery plan. CSSIW have attended a large number of strategy
meetings regarding missed calls. It has been noted in the safeguarding referrals that some
people have not had their needs met with regard to medication, nutrition and personal care
in particular continence needs. Bryce Care must ensure that the personal care that the
agency arranges must meet the service user’s needs as specified in the service delivery
plan.
The impact on people using the service is that they are being potentially neglected and put
at risk as their individual care needs are not being met.
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Version 1.1 07/2012
Quality of environment
Non compliance identified at this inspection and action to be taken
Action to be taken
Timescale for
completion
Regulation number
3