CFT Care Limited

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 inspection we rated this key question good. At this inspection the rating has changed to 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 provider was in breach of the legal regulations in relation to safe care and treatment.
 

This service scored 50 (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 had processes in place to analyse accidents and incidents in order to identify trends and themes. However, these processes were not always robust. For example, we found some incidents were not being logged on the provider’s electronic system accurately. This meant not all incidents had been reviewed by management to identify learning and minimise the risk of a reoccurrence. The provider responded promptly to our feedback during the inspection, making immediate changes to their system to ensure all concerns were escalated appropriately.

The provider had a process in place for sharing lessons learnt across the wider organisation. However, it was not always clear from staff meeting minutes how learning was being shared with staff teams to ensure improvements were made and good practice embedded.
 

The provider did not have robust systems in place to work with people and healthcare partners to establish and maintain safe systems of care. We received mixed feedback from people’s relatives and healthcare professionals about how well transitions were managed. We found some people had all appropriate support in place to promote consistency in their care when moving into the service. However, we also found examples of recommendations and support not being implemented effectively leading to breakdowns in people’s placements. People did not consistently receive positive transitions into the service.

The provider had processes in place for recording and tracking safeguarding concerns. However, these processes were not always operating effectively. During the inspection we found some safeguarding concerns had not been identified by the provider’s internal incident management processes. This meant we could not be assured concerns had been escalated to the relevant authorities with appropriate actions taken. Following our feedback, the provider responded promptly to amend their system and raise retrospective safeguarding notifications to evidence action taken.

Where people had restrictions in place for safety reasons, these were clearly recorded with appropriate documentation in place to evidence when and why they may be required.
 

The provider did not always work well with people to understand and manage risks. Risks to people’s health and safety were not always documented appropriately.
Whilst we found some people had risk assessments in place for all assessed risks, we found other people did not. Where risk assessments were in place, these were not always accurate or up to date. During the inspection we identified inconsistencies with risk management documentation relating to people’s mobility needs, eating and drinking support needs and seizure management.

People’s personal emergency evacuation plans (PEEPs), detailing how to support them to evacuate safely in the event of a fire, did not contain all relevant information. For example, information about the medicines people were taking and the impact this may have on people’s ability to safely evacuate were not recorded.

Following our feedback, the provider responded promptly to confirm they were reviewing and updating the relevant risk assessment and fire evacuation documentation.
 

The provider had processes in place to identify potential risks in people’s home environments. However, during the inspection we found concerns which had not been identified by the provider’s environmental safety checks. For example, we found an uncovered radiator and a fire door which had been wedged open. Practice fire evacuation drills were not being routinely completed in services despite this being identified as an action in the provider’s service improvement plan.

The provider told us fire drills had been scheduled across all services. However, at the time of the inspection, the provider was not able to demonstrate these had been scheduled or completed.
 

The provider made sure staff were safely recruited. Appropriate recruitment policies and processes were in place and relevant employment checks had been completed. The provider had taken positive steps to promote people’s involvement in recruiting staff, including supporting them to write personalised job adverts to identify what was important to them when choosing staff to support them.

However, we identified concerns with the training and ongoing support for staff once employed. For example, staff had not always received regular supervisions or appraisals to ensure they were supported in their role and to promote their development.

Not all staff had completed relevant training to ensure they were appropriately skilled and qualified to support people safely. For example, the provider’s training matrix demonstrated not all staff had up to date mandatory training such as fire safety and infection prevention and control. We also found not all staff had completed relevant specialist training. For example, in courses related to managing risks associated with people’s physical and mental health needs.

The provider was able to demonstrate they were aware of the shortfalls in training, supervision and appraisal. A training matrix was in place to identify and address concerns with individual staff compliance and supervisions were scheduled. The provider had also taken proactive steps to implement new bitesize training covering a range of relevant specialisms such as person-centred care and use the of positive terminology.
 

The provider did not consistently assess and manage the risk of infection. During the inspection, we identified issues with the cleanliness of some people’s home environments including stained furniture in need of replacement and bathrooms which required deep cleaning.

The provider responded promptly to replace furniture and address the cleaning issues identified.
 

The provider had systems in place to monitor the safe administration of medicines. However, we found medicines audits had not always identified issues with documentation and administration. For example, we found a protocol for an as and when required medicines which contained contradictory and inaccurate information. We also found a medicines error relating to the administration of this medicine which had not been identified by the provider. Following our feedback, the provider took prompt action to update the relevant documentation and investigate the error.

The provider was able to demonstrate how their auditing had identified an increase in medicines errors over a period of time and the steps they had taken to address shortfalls in staff training and practice. During the site visits, we found people’s medicines were safely stored and staff had completed the appropriate documentation to show when medicines had been administered.