Archived: Caremark Swindon

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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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to safe care and treatment and staffing.

This service scored 31 (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. For example, at the time of our site visit, there was no document available to record collective incidents or collective actions taken, to enable the service to monitor for any themes or trends. As a result, we found similar incidents had occurred. The NI told us, “I know we aren't keeping an incident log at the moment, but I have started to think about this.” The NI later sent a spreadsheet with all incidents for the last 12 months as requested by CQC. However, the section recording any lessons learned had not been completed for most of the incidents recorded, including for medicines errors and an incident relating to catheter care and support. Where lessons learned were recorded, the only staff involved in these discussions were staff working in the office, and there was no process in place to communicate the learning to care staff. When concerns were raised about people’s risks, action was not always taken to address these, leaving people at continued risk of harm. For example, we requested immediate assurances in relation to unclear guidance in a care plan for a person who was at risk of choking. The NI provided an updated care plan in response to this request, however, this still contained references to foods which contradicted guidance provided by the SALT team, putting the person at continued significant risk of choking.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. People had documents in place to support safe potential transitions into hospital, which included information about people’s allergies, communication needs, risks, and food safety. However, one person’s hospital passport contained advice which contradicted advice from the SALT team. We saw one example of an unsafe discharge from hospital for one person. The provider took action to address this including raising a safeguarding referral with the local authority and working with the hospital team to improve communication between the services, however they did not notify the Care Quality Commission in line with their legal obligations.

We requested a copy of the safeguarding policy for the service; however, this was sent as a template and had not been completed with relevant contact details, such as for the local safeguarding team, which meant staff may not be able to follow this process effectively. Additionally, one staff member told us staff did not have access to policies and procedures. Staff did not always feel concerns would be appropriately addressed. One staff member expressed confidence their supervisor would address their safeguarding concerns, but felt the nominated individual (NI) lacked knowledge in this area. There was no process in place for leaders to monitor for trends and themes following accidents and incidents, meaning there was a lack of oversight in the way potential safeguarding concerns were managed. During our site visit, we identified a safeguarding concern which had not been identified by staff or leaders working at the service, and we made a referral to the local authority safeguarding team for these concerns and requested immediate assurances in relation to this. However, people and their relatives told us they felt safe and raised no safeguarding concerns. Staff had completed training in safeguarding and had some understanding of what this meant. For example, staff were able to describe different types of abuse.

Care plans did not contain adequate information to support staff to manage people’s risks safely. We found one person, who was assessed to be at risk of choking, had guidance within their care plan which contradicted advice provided by a speech and language therapist (SALT), putting this person at high risk of choking. The person’s care plan guided staff to leave snacks, despite this person being assessed to require ‘soft and bite sized’ foods. There was no guidance within this person’s care plan to inform staff which foods were safe for the person to eat. Staff and daily records confirmed foods such as sandwiches and crisps were being offered to the person regularly and that the person’s SALT guidance was not always being followed. Leaders had not identified this which put the person at high risk of choking and was a safeguarding concern. Some records showed that at times, the person struggled to eat some meals, leading to the meal being taken away and leaving the person without food. There was no evidence that further advice had been sought and leaders had not identified this through reviews of daily records. Additionally, we found information from people’s risk assessments was not always transferred to people’s care and support plans. This meant staff did not always have the information required to support people to manage these risks safely. Staff told us they did not have the training or guidance to support people to manage risks safely. For example, one staff member told us about people experiencing frequent urinary tract infections due to staff not receiving appropriate training in catheter care.

People and their relatives raised no concerns about their environment. Staff told us people’s environments were assessed before care was delivered. The provider helped people obtain equipment to support their mobility and independence, such as a swivel chair. There was a business continuity plan in place for the service, which assessed risks relating to the environment. However, this was not always appropriate for the service, or accurate, and this had not been fully completed in some areas. The service had a fire risk assessment in place, which identified one staff member may not hear the alarm due to a hearing problem, however, there was no information within the risk assessment about how this risk should be managed.

Staff had not completed training relevant to their role, which impacted their ability to deliver safe care. One staff member told us, “From what I can recall, I did not have enough training on pressure damage” and “I was not fully trained on catheters. I got told about it and read information on it. No one came in and showed us like they did with stoma training. Every supervision I had, I expressed that I wanted more training on this. I am still waiting.” A staff member told us people experienced frequent urinary tract infections as a result and we saw some evidence of this. Another staff member told us, “[Person] is also diabetic, and we’ve had no training in diabetes whatsoever.” We reviewed the service’s training matrix which supported this feedback. Additionally, training was being delivered to staff, in some cases, by people who did not have the appropriate skills, qualifications and experience to do so. For example, staff were trained in medicines by a person who was not qualified to do so. We saw various medicines errors which had occurred as a result. Staff had not always been recruited safely in line with legislation. For example, one staff member had gaps in their employment history which had not been explored. This meant the employer could not be assured the staff member was of good character. However, the provider undertook other relevant checks such as ensuring staff had an appropriate Disclosure and Barring Service (DBS) check.

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. Staff told us personal protective equipment (PPE) was stored at the office, and they had access to this. Staff had completed online training in infection control and there was a policy in place. People and their relatives told us staff wore protective gloves and washed their hands. We saw infection control was discussed in team meetings and no concerns were raised by people or staff.

Medicines were not managed safely. Staff told us about regular medicines errors and told us leaders were not always knowledgeable about actions to take following these. For example, one staff member told us they had been advised to dispose of medication in a person’s household waste, which was not in line with the providers own policy, which stated this should be returned to the pharmacy. Practical medicines training was delivered to staff by a staff member who did not have the skills, experience or qualifications to do so safely. This meant staff were not appropriately trained, and we found medicine errors occurred frequently. In one audit, looking at medicine records within a week’s duration, it was identified there were 19 occasions where there was not a recommended 4-hour gap recorded in between doses of co-codamol for one person, which meant there was a risk this person was being overdosed. Audits identified many recording issues among staff. These audits did not always appear effective as we found similar trends occurred, such as staff recording errors. People had ‘when required’ (PRN) protocols in place, but these lacked detail. For example, one person had a PRN protocol for Co-codamol but this did not include any details about how many tablets should be administered and how to recognise when these should be administered. People had risk assessments in place for medicines, however these did not always assess associated risks, such as the risks of flammable paraffin-based creams being applied to people and how to manage these. However, there was a medicines policy in place and staff had completed some online training.