Poor Record Keeping and Non-Existent Risk Assessments Contributed to CQC Cancelling Care Service Registration

Satellite Consortium Limited (SCL), a domiciliary care service, in the London borough of Haringey, has had its registration cancelled by the Care Quality Commission - effectively closing it down.

SCL was a domiciliary care service registered to provide personal care to people in their own homes. The service provided care and support for older people, people with physical and learning disabilities and sensory impairment and people living with dementia. At the time of inspection, the service was providing personal care to 68 people.

The CQC moved to cancel the provider’s registration following an inspection in October 2017 – but it has taken until now to complete the legal processes involved.

Key Issues

• Satellite Consortium Limited did not have a registered manager in post, which impacted on the leadership and governance at the service. 
• The provider lacked robust and effective systems to assess, monitor and evaluate the safety and quality of the service and did not carry out regular internal audits to identify areas of concern and improvements.
• People using the service did not get the care they needed as sometimes staff failed to turn up and when care was delivered it was frequently late. 
• The quality of care was also not good enough, people were put at risk by poor care practice which failed to meet their needs.
• The CQC reviewed 13 people's care plans and found that none of the care plans had risk assessments instructing staff on the risks involved in supporting them and how to safely manage those risks. For example, one person had high mobility needs, was at risk of pressure ulcers as they spent the majority of their time in bed and used a hoist and bed rails for safety. This person had not been identified as being at high risk of pressure ulcers and there were no risk assessments in place to ensure their mobility and care needs were safely met or to instruct staff how to minimise risks involved in supporting the person. This placed the person at high levels of risk of avoidable harm.
• People deemed to lack capacity, did not have their capacity assessed. Staff were not trained in the Mental Capacity Act and were not provided with information on how to encourage people to make decisions.
• SCL did not follow safe and appropriate staff recruitment practices and did not effectively monitor staff punctuality and timekeeping with missed and late visits not being recorded. 
• The provider did not notify CQC of two safeguarding cases. Not all staff received safeguarding training and staff lacked understanding of how to identify and report abuse. Safeguarding records did not give details on the investigation outcomes.

Debbie Ivanova, CQC’s Deputy Chief Inspector of Adult Social Care, said "Every client of Satellite Consortium Limited was entitled to receive a good standard of care. Unfortunately that was not the case and on this occasion we have had to use our enforcement powers to cancel the provider’s registration.”