Great Care Health Services

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 good. At this assessment the rating is requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness. Lessons were not always learnt to continually identify and embed good practice.

The oversight and management of safety events was not always effective. Where accidents and incidents had been documented, the information detailed about how incidents had occurred and what had happened following incidents, such as the actions taken by staff and whether external healthcare professionals had been involved, was not always adequate. Safety events had not always been reviewed and analysed by the provider for understanding and learning. This meant people were at risk of accidents and incidents not being appropriately managed.

There was a lack of an effective learning culture in other areas. For example, staff meetings were not completed on a regular basis by the provider. This meant staff did not have the opportunity to share learning to improve the safety of the service.

The provider did not always ensure safe systems of care. They did not always manage or monitor people’s safety.

The provider did not have effective systems of monitoring and managing safety in the service. For example, concerns regarding the management of safety events, safeguarding and awareness of the principles of the Mental Capacity Act 2005 (MCA), had not been identified or acted upon to ensure people were consistently safe. This meant people were exposed to avoidable harm.

People and relatives told us the transition process for people before they received care from the service had been positive and effective. The provider explained what the transition process was for people, and how the information obtained during this process was used to develop people’s care records.

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 protecting their right to live in safety, free from avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider failed to always record, manage and report safety incidents that had occurred and had affected people’s health, safety and welfare. Where accident and incident records showed people had been exposed to risk of harm, these incidents had not always been reviewed by leaders, nor reported to external partners, such as CQC. Failure to ensure safeguarding incidents were reported demonstrated ineffective safeguarding processes which increased the risk of a recurrence of incidents.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA). Where people had been judged as having the mental capacity to be able toconsent to their care arrangements, they had not always been provided the opportunity to do so. Where people had been judged as lacking mental capacity to be able to consent to their care arrangements, decision-specific mental capacity assessments regarding key aspects of people’s care had not been carried out, and best interest decisions had not taken place to demonstrate decisions taken on people’s behalf were being taken in their best interests.

The provider did not always work well with people to understand and manage risks.

People’s care plans did not always provide information which accurately reflected people’s needs and risks. For example, care plans did not always provide information which adequately detailed people’s physical health, mobility and safety needs. Where people had mobility needs, adequate guidance was not available to staff, meaning staff unfamiliar with people’s needs might not be able to support them effectively. This exposed people and staff to the risk of harm.

Staff demonstrated an awareness of the risks associated with people and how they should be supported.

The provider detected and controlled potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care.

Staff received health and safety training and demonstrated a good awareness of how to ensure people’s home environments and mobility equipment were maintained to mitigate potential associated risks.

The provider completed observational checks of people’s home environments as part of the quality assurance checks they completed of staff.

The provider did not make sure there were enough skilled staff.

Staff had not received training which was relevant to support some people’s needs. For example, staff had not received aspiration, mental health and catheter training. Staff were unaware of health conditions some people had. This meant people were at risk of their needs not always being provided by competent staff.

Safe recruitment processes were followed, and staff received inductions and regular supervisions with leaders. People and relatives were satisfied staff demonstrated the skills they needed to provide safe care.

The provider assessed and managed the risk of infection.

The service had an Infection Prevention and Control (IPC) policy which set out the provider’s IPC expectations. Staff received training IPC. Supplies of personal protective equipment (PPE) were observed in the office, which staff told us they had access to when they needed it.

People and relatives said staff used PPE when providing care, with 1 relative saying, “They wear aprons and gloves as they help my [ relative].” However, the feedback from staff was mixed, with 1 staff member telling us staff did not always use PPE when they were required to.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

A medicines policy was in place and staff received training in safe medicines management. Staff we spoke with demonstrated a good awareness of medicines processes and people’s individual medicine needs. People and relatives told us they were happy with the medicines support they received from staff.