Carters Green Healthcare Services 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.

This is the first assessment for this service. This key question has been rated 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 and safeguarding service users from abuse and improper 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.

Where safety events had occurred, these were not always documented on incident records, with some incidents recorded on people’s daily notes instead. This meant incidents were not always coming to the attention of leaders. Where this was the case, the information documented in daily care records was sometimes unclear and imprecise. Where safety events were documented on incident records, most of these incidents did not detail post-incident information, such as the actions taken by staff and whether external healthcare professionals had been contacted. We found only incidents relating to the use of physical restraint had been reviewed by leaders. Many other recorded incidents were not reviewed nor analysed by leaders for understanding and learning.

Staff and leaders told us they were unclear which incidents needed to be documented on incident records, and which did not. Leaders acknowledged the need for improvement following our feedback. This meant people were at risk of safety events not being appropriately managed.

The lack of a learning culturewas also evident in the lack of governance audits leaders completed in other areas. For example, people’s care plans were not audited by leaders and, despite staff meeting minutes detailing there were issues with some staff call times, leaders did not routinely audit people’s call times. However, there were other examples of the registered manager having shared concerns the service had received with staff within team meetings to raise awareness and support learning.

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

As reported elsewhere in this report, effective systems were not in place to ensure safety was consistently and effectively monitored and managed at the service. For example, concerns regarding the management of safety events, safeguarding, people’s care plans, awareness of the principles of the Mental Capacity Act 2005 (MCA), and knowledge of Right support, right care, right culture statutory guidance had not been identified or acted upon to ensure people were consistently safe. This meant people were exposed to avoidable risk.

No concerns were shared by relatives regarding the transition process for people before they moved to the service. The registered manager described this process, which included obtaining information regarding people’s care and support needs so this information could be reflected in their care records. The relatives we spoke with informed us they had been involved in care planning processes.
 

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.

Safety event records showed people had been exposed to risk and harm. However, these incidents had not always been effectively reviewed by leaders, which could have supported

understanding and learning of such events. This meant there was an increased risk of recurrence of incidents, which exposed people to avoidable harm.
There were inconsistencies in relation to reporting safeguarding concerns to external partners, such as the local authority and CQC. We found some incidents were reported as required, while others were not. For example, neither the local authority nor CQC had always been notified in instances in which there had been allegations of abuse and police involvement.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In homecare services, where a person is suspected as lacking mental capacity in relevant areas, this can be done through an application to the Court of Protection, which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they sought authorisation regarding the use of restrictive practices and found, where this was applicable, people did not have a court order issued by the Court of Protection which legally authorised these deprivations of liberty. When we spoke with leaders regarding the situation, they informed us they were unaware authorisation was required. This meant people were being deprived of their liberty without the legal authority to do so.

There was a safeguarding policy in place, records showed staff had completed safeguarding training, staff were able to tell us the action they would take if they had concerns, and relatives told us they felt their relatives were receiving safe care.

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

People’s care plans and risk assessments did not always provide information which accurately reflected people’s needs and risks. For example, personal care and dressing care plans and risk assessments did not always provide information which detailed how staff should support a person with their dressing needs. We found a person’s behaviour care plan and risk assessment failed to detail what staff should do in response to a person displaying heightened emotional reactions. We also found a person’s care plan stated they had not experienced a health-related episode for a significant period of time, the person’s daily care records demonstrated they had experienced an episode. However, their care plan had not been updated to reflect their current health status. This meant there was not always guidance for staff on how they could keep people safe, which exposed people to the risk of harm.

There were some examples of care plans and risk assessments providing accurate and person-centred information, and staff we spoke with demonstrated a good awareness of the risks associated with people and how these could 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.

The provider identified and mitigated potential risks in the care environment. Staff received training in the use of equipment involved in people’s care, they told us they knew how to use this safely and senior staff completed observation checks to ensure this was the case. People’s care plans and risk assessments also mostly contained clear information how staff are to use equipment and mitigate potential risks in people’s environments.
 

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Staff recruitment records demonstrated safe and robust recruitment practices were carried out. We saw staff received a wide range of both online and face-to-face training relevant to people’s needs, which both staff and most relatives confirmed. Records showed staff received comprehensive inductions and that most staff received regular supervisions with leaders. Relatives also told us new staff shadowed more experienced colleagues before being able to work with people by themselves.

Relatives were confident staff had the skills they needed to provide safe care. One relative said of staff, “They have had the training - the awareness of autism and learning disability and we know they are aware of [person’s] needs – they are very understanding.”
 

The provider assessed and managed the risk of infection.

Training records showed and staff confirmed they received training in infection prevention and control (IPC), and staff told us they had access to personal protective equipment when they needed it. The service had an IPC policy which set out their IPC expectations.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff received training in safe medicines management and staff we spoke with demonstrated good awareness of medicines processes and people’s individual medicine needs.

Clear systems and processes were in place regarding the administration and documentation of people’s medicines. Leaders told us how they used an electronic medicine system to monitor medicine practices, and they also completed regular medicine observation checks and audits to ensure safe and appropriate medicines practices.