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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During our assessment of this key question, we found concerns around staff recruitment which resulted in a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Managers made sure recruitment checks were undertaken on all staff to ensure only those individuals that were deemed suitable and fit, would be employed to support people at the service. However, the recording of this was not robust and some gaps in employment for staff had not been fully explored by the provider at the commencement of staff employment. People and those important to them were supported to understand safeguarding and how to raise concerns when they did not feel safe. Staff understood their duty to protect people from abuse and knew how and when to report any concerns. When concerns had been raised, managers reported these promptly to the relevant agencies and worked proactively with them, to make sure timely action was taken to safeguard people from further risk. Safety risks to people were managed well. Managers assessed and reviewed risks to people and made sure people and those important to them, were involved in making decisions about how they wished to be supported to stay safe. There were enough staff to support people with their needs. Managers reviewed staffing levels regularly to make sure there were always enough suitably skilled and experienced staff on duty. Staff received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives we spoke with gave positive feedback overall regarding feeling safe with staff. One concern was around the lack of knowledge of new staff, "The regular staff know what to do, the newer ones are inexperienced, they still treat my family member nicely though. She is safe, they are all nice.”

Staff told us there were regular meetings where important information was shared. We found limited evidence of lessons learned being implemented to improve care where shortfalls had occurred. For example, when a concern or complaint had been raised, the provider had cancelled contracts with people, citing challenges and difficulties, rather than attempting to seek a resolution. Staff knew how to report their concerns and were knowledgeable about safeguarding processes. Staff we spoke with showed a clear understanding of safeguarding process and signs of risks and abuse and were confident in raising concerns with the RM. One staff member told us, "Training was good, I completed this before commencing with care visits. I feel confident raising concerns with the [registered manager]RM or [Local Authority]LA as appropriate. I am confident to speak with RM or [Nominated Individual]NI. They are approachable and available.” Staff we spoke with told us they attended occasional staff meetings and felt kept up to date on information.

The provider used a client survey to assess the satisfaction of people and their relatives with the quality and safety of the service. The provider had created an action plan from the feedback obtained from people in which they identified areas to improve service provision. These actions would be considered as standard quality auditing in a well run service, for example, ensuring regular review of care packages, ensuring staff always wore name badges and introducing new care staff for people. The provider had not identified these areas as a shortfall in service provision prior to the survey being returned.

Some people and their relatives gave feedback regarding a lack of consistency in the staff attending people's care calls, which they felt had largely been addressed when raised. Some inconsistency with timing of the care calls for people was raised as a concern for some people. A number of people have had care plans created by the hospital discharge team and did not feel they had had a review in a timely manner. One relative told us, “We have been with the service for about a year and have no complaints and no concerns but I’m sure that I could raise any. Yes, I’m involved as I’m the sole carer and the care plan is somewhere, I don’t know when it is due for a review. I have contact numbers in a folder and on my phone. I raised a concern last week because we were getting a different carer all the time and my family member needs the same staff that they can recognise, they need consistency. I'm pleased to say that we now have 2-3 regulars, its lovely now.”

Staff understood the importance of working with partner agencies to deliver joined up care for people. One staff member told us how they worked with health teams to support people; they discussed monitoring the output for a person with a catheter and fed this back to the District Nursing Team. They understood how to escalate concerns in an emergency.

We received mixed feedback from commissioners working with the service. One commissioner who had carried out a recent compliance visit had found the service to be performing at a high level, whilst others had suspended contracts due to significant concerns raised around staff recruitment practices. The provider had not declared these concerns at the time to their commissioners, which had left some commissioners concerned about the openness and transparency of the provider.

Care plans were person-centred and risks had been assessed with clear guidance for staff to support people in their chosen way. Where people had been identified as having additional risks or extra needs these were clearly documented and staff completed daily records to ensure people remained safe. Where people were identified as at risk of falls there were appropriate risk assessments in place and guidance to support staff with equipment requirements such as hoists or walking aids.

People told us that they felt safe with the care staff. People told us they were aware of how to raise any concerns and where they had done this, the management team had responded appropriately. People told us having regular care staff made a difference to how they felt about their care. However, some people and relatives reported that they did not feel as confident with newly employed and less regular care staff. Some concerns were shared by people and their relatives in regard to safety issues. One relative told us, “I had to raise a couple of concerns, [staff] turned up at 6.30am and 6.45am in the morning and I rang to say that that was completely unacceptable and now they come between 8am and 9am. They do the stoma bag but they once sent someone that wasn’t trained and someone who didn’t know what to do but that is sorted now. I have contact numbers and I had never met any of the carers before, they just turned up, I think that there should have been an assessment before they came. One staff member is really good and has a good rapport with my family member, they prefer women to men. They are very safe with this staff member, they even took them to the shops which gave me a break.”

Staff told us they had completed safeguarding training, and they were familiar with whistleblowing processes. Staff were aware of internal and external reporting for safeguarding concerns, as well as how to escalate any concerns within the organisation. One staff member told us, “I am clear about safeguarding processes. We have access to a buddy system for staff welfare called Lifeline, which tracks where we are, any concerns out of range are picked up.”

The provider had policies and procedures in place in relation to safeguarding and whistleblowing and provided staff with training to ensure that they could respond appropriately to any concerns. Concerns were reported by the management team which included reporting to the local authority safeguarding team and making statutory notifications to CQC. We saw a service user guide was given to people when they began using the service which gave them information about how to make a complaint or raise a concern.

Some people and relatives felt they could be more involved in planning their care. One relative told us, “We have been with them for 5 months, the Social Services sorted the care plan, I was not involved. We have a number to ring. The carers have said that they need more time to support my relative with mealtimes, so visits have increased, but we feel less daily visits would be ample and they could extend the meal times so as not to rush her food. My relative lives with sight loss and has a degenerative condition, but they seem okay with them, there can sometimes be a bit of a language barrier from a conversation point of view.”

Staff told us they supported people to be involved in managing risk themselves. One staff member told us, “The care plans are updated regularly. Information is cascaded to staff via our group contact if it is urgent and updated in the live system as ongoing. We can't do anything well without proper plans in place.”

The registered manager spoke with us about care planning and how they involved people to manage risks. The registered manager had conducted a survey with people and their relatives which showed that the majority of people were happy with the level of involvement in their care planning. We reviewed risk assessments as part of people’s care plans which described actions for staff to take to support people to manage risk and keep them safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some people reported there were changes from the staff who regularly came to support them. Feedback given to our Expert by Experience overall indicated that people and their relatives felt new staff lacked experience, which showed in their approach and understanding of people's needs. Other comments were more favourable, with people commenting they felt safe with staff and their level of training. One person said, “We can definitely raise any concerns if necessary. The hospital did the care plan and it's probably due for a review at any time soon. They are well trained as they come to shower my family member, they are very safe as they are very gentle with them.”

Staff felt they had the right level of training to carry out their role safely and effectively and received on-going support and supervision. Staff told us they received an induction before they started providing care to people. One staff member told us, “I received training and induction before I commenced care calls. I shadowed another staff member first.”

The provider did not always follow as safe, robust recruitment process. Recruitment records were incomplete, and the provider had failed to follow their own policy. One set of interview notes was not dated and there was no record of who had conducted the interview. Application forms were not completed in full, there was not always a full employment or education history, and no exploration of gaps in employment. Staff files contained references but these had not been verified. One record reviewed did not contain documentation relating to proof of address. The staff files were disorganised and it was difficult to locate accurate information as some files contained multiple contracts with differing dates. The provider was able to clarify this was due to an extension to people's initial visa and so a further contract had been created that had a different set of dates on to reflect this. The provider had carried out a Disclosure and Barring Service (DBS) check on candidates as part of their recruitment process. A DBS check is a way for employers to check a staff members criminal record, to help decide whether they are a suitable person to work for them. The provider had a current policy and procedure relating to recruitment, but they did not appear to consistently follow the policy guidance. For example; gaps in employment are not recorded and explored as part of the interview process. The provider did not consistently ensure there were enough qualified, skilled and experienced staff. We reviewed 8 staff records and found that 4 out of the 6 staff files contained incomplete induction records. We observed the provider had a training matrix which evidenced staff were receiving training to support them to safely and effectively carry out their role. The registered manager carried out competency assessments with staff to ensure they could safely support people with their medicines.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some relatives told us they had concerns about the medicines management processes the service had in place for their family members. One person lived with sight loss, and their relative told us, “Oh they change carers all the time and we keep having to go through what medication that [name] needs. She needs a `Blister Pack` to assist with medicines, someone needs to put something in place.” We raised this with the provider following our visit and requested they set up a review with the relevant teams to request the medicines are reviewed to ensure the person can access them safely.

Staff told us they had received medicines training and understood the importance of recording this correctly where they assisted people to take medicines. Any changes in medicines were communicated to staff by the care co-ordinators to ensure this was actioned. This was recorded in people’s care plans.

The provider ensured medicine records were audited regularly and any errors were identified. The provider ensured staff received training and competency checks to ensure they were assessed as competent in medicines administration.