Gemcare South West - Extra Care Scheme

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, medicines, staffing, governance at the service, and notifications.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

People and relatives told us when they had raised safety concerns, they were not listened to nor responded to effectively. One person said they had reported concerns to senior management on 2 occasions, and no action was taken. When we identified a safety concern, we asked the person if they had reported it, the person said, “What’s the point, managers don’t want to know.”

Some staff told us of occasions where they had raised concerns and completed incident forms but had not been listened to, and no action was taken.

The service sent us information relating to complaints, safeguarding, and incidents. However, we were not assured that all concerns had been reported, investigated and lessons learnt. For example, most complaints did not contain information about the investigation and outcomes. We asked for investigations relating to some incidents and did not receive a response.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

We identified a person without a care plan. They had received a service for a month before our assessment. They did not have a care plan until this was raised by inspectors. This placed them at risk of unsafe care as staff did not have information on how to safely manage their needs.

A staff member said, “When we have a new resident their care plan is not issued to us for sometimes quite a while.”

Another person told us, “I did have 2 missed calls when I came out of hospital apparently the carers were not told I was home don’t know why that was as I heard the hospital speaking to someone to tell them.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Some people told us they felt unsafe. One person said, “I have raised safeguarding concerns about myself on more than one occasion. I never received a response.” Another person told us, “I have never felt as scared as I do now. I am afraid someone will physically abuse me next time or be hurt again.”

Staff had the skills and knowledge to raise concerns about abuse or neglect.However, we were not assured staff’s safety concerns would be listened to. One staff member told us they would contact the CQC as they had no faith in the provider to take action.

The provider had safeguarding policies and procedures available for staff and leaders, but these were not always followed when a safeguarding incident occurred. The service had logged allegations of abuse but had not informed the CQC of the incidents as legally required.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a lack of written guidance for staff relating to diabetes, catheter care, moving and handling, and people’s medical conditions. People’s needs were not being monitored, and action was not being taken when risks were identified.

A relative told us, “I see where her catheter is sometimes overfull and not emptied which is not healthy for her. Also, at times even as the day goes on there can be hardly anything in her catheter bag and I think she can get dehydrated fairly regularly.”

Some staff did not record the care provided on their visits. This meant care staff did not have full information about what had happened at the previous visit. This placed people at risk of receiving unsafe care and support.

One of the units was not fully secure which risked people gaining unauthorised access. The provider did not always detect and control potential risks in the care environment.

We were able to access one of the units without anyone checking who we were. We could not see any care staff and only spoke with a staff member after we pulled a call bell in a communal area.

The service carried out environmental risk assessments for each person they supported. These identified potential risks in people’s home and how to manage them.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Records showed early and late calls. This impacted on people’s daily routine and put them at risk of potential harm. Records showed a lot of visits had been cut short. People told us that staff frequently did not stay for the full length of the visit, staff did not complete their care and rushed them. One person told us staff did not always have time to shower or shave them. A staff member said, “You end up having to cut everyone’s care and it is putting people at risk and then us at risk as we are running around trying to get everything done.”

Several people told us they should have 2 staff to assist them, but they did not always attend for the whole visit as they were needed elsewhere. One person told us a staff member had left them whilst they were still in the hoist to attend to another call bell. This meant people’s care was not being delivered as agreed and placed them at risk.

Several staff told us of occasions where they had been in a unit on their own as other staff had not arrived. Staff said, “There is not enough staff in the building for the amount of people we have so we are often double booked, we can't spend the right amount of time with the resident and the calls are cut.” They also told us about missed visits. A staff member said, “Some calls just don’t appear, and you don’t realise until the next time you speak to them and there is so much of it, so it is hard to keep on top of it.”

Another staff member said, “Shift shortages are frequent and often ignored, with employees pressured to cover excessive workloads without adequate breaks or assistance. The result is not only burnout but avoidable harm to those under our care.” We identified one staff member had carried out 40 visits in a day and were often cutting their visits short.

People told us their regular care staff knew how to meet their needs and felt they were trained but new staff and agency staff did not. One person said, “I try to get a shower on a Friday because most weekends they are agency, and they don’t know what they are doing.” Another person who had moving and handling needs told us “Staff sometimes get the slings wrong.” A third person said, “New staff don’t have enough training – some don’t know what a catheter is.”

Staff said, “It would be nice if new starters would be assessed and observed often, it does not happen very much at all so I don’t think they are getting the support so either accidents would happen, or they will leave” and “Training from a mobile app I find quite horrendous and feel for new staff.”

Staff had not always received effective support, supervision and development. They did not always work well together to provide safe care that met people’s individual needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Some staff, across different units, told us they did not always have enough personal protective equipment (PPE). Several staff told us they did not have access to the correct sized gloves.The provider told us they had addressed this issue and services could now order PPE themselves.

People told us staff wore PPE appropriately during their care visits.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

There were a number of gaps in administration on medicines administration records. Agency staff were not provided with phones to record when they had administered medicines. The provider was not ensuring medicines were administered in line with their policy which placed people at risk of harm.

Staff told us they did not know what time agency staff gave medicines as it was not able to be recorded. This meant they were unable to administer medicines safely.

People told us variable visit times affected their medicines. One person said, “Yesterday they started off late and as the time went on they said they couldn't do anything about it. All my medication was late which does then affect what I'm able to do because the timing of the Parkinson's medication is very important.”

Staff told us people had missed medicines. We found several people had run out of their medicine which meant they had not received them as prescribed.

Some people told us they were happy with the way their medicines were managed.