Caremark (Wokingham and Bracknell)

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 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 person-centred care, safe care and treatment and staffing.

This service scored 34 (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 demonstrate a proactive and positive culture of learning in order to improve people’s safety. The provider did not have systems and processes in place to support a learning culture to improve practice and mitigate future risks and keep people safe.

People told us about staff, “Some of the new ones take a while to learn how to do things” and “I think they are trained but they just don’t seem to read what it is they are meant to be doing before they come in.”

Records did not detail actions taken following incidents such as ensuring care plans and risk assessments were updated. There was limited information recorded on how incidents occurred and what measures were put in place to minimise future risks.

Incidents and complaints were not appropriately investigated and reported. For example, the concerns log documented a professional raised concerns on behalf of a person in relation to personal care and moving and handling, There were no records of detailing the specific actions taken and therefore no lessons could be learnt. It was not clear how any change or deterioration in people’s needs was being monitored to ensure their safety and mitigate risks.

Learning was not always documented to ensure the service learned from safety incidents, which would result in changes that improved care for others. Records did not show who had oversight of follow up actions, if lessons were shared with the wider team and did not clarify how concerns were reported and who they were reported to.

The provider did not always work well with people or maintain accurate records to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

People told us after they were discharged from hospital,“The company came and saw me and sorted everything out” and “I was discharged with a care package from them, and it’s all been fine.”

Relatives told us the service arranged support through a range of professionals, such as occupational therapist, One relative told us, "A carer will usually come with us to GP appointments and other appointments when necessary.”

Staff told us they approached professionals such as district nurses and the physiotherapist for support. One member of staff told us, “I spend a lot of time consulting, talking to professionals and family and the client.”

Despite some positive feedback received, care records contained conflicting information and therefore care records were not up to date which could impact the way services work together to ensure safe transitions between services. There was limited evidence available to guide staff on how to communicate with people, which could impact how people were supported with their independence, monitoring their health and daily life.

Due to the poor quality and lack of personalised care plans and risk assessments, we were not assured transitions and continuity of care would be safely managed.

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 service did not always share concerns promptly or appropriately. The service’s safeguarding records were incomplete and managerial oversight of safeguarding concerns was insufficient to keep people safe. The service did not have clear records to evidence if safeguarding matters had been reported, and if notifications had been raised with CQC as required by law. Safeguarding concerns were not evidenced as being raised with the correct authority due to the lack of oversight and it was not clear who took responsibility. Therefore, the service could not determine if safeguarding had been raised to keep people safe.

The safeguarding records were inaccurate and did not contain enough information. Records did not contain actions and safeguarding referrals were not always raised by service. The provider did not have an effective system in place for reviewing and investigating safety and safeguarding incidents and events that go wrong. During the inspection we found staff had not raised a safeguarding referral for one person, and there was limited evidence in place to ensure the person and staff supporting the person were kept safe.

The service failed to identify shortfalls such as themes and trends to see where improvements could be made to ensure people’s safety was not compromised. Safe systems and processes were not in place to identify, monitor and report safeguarding concerns. Systems to ensure that people were safeguarded from abuse and improper treatment were poor and ineffective.

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.

Care records showed there were insufficient details to support staff to understand and manage risk and were not person specific or person-centred.

Risks were not assessed with people for staff to understand them. Shortfalls were identified in risk assessments in a wide range of areas including choking, pressure care, diabetes, falls and supporting people in distress. People did not have adequate guidance in place to receive support from staff as risk assessments were not updated to reflect pressure care concerns.

Where people needed support to communicate their needs, emotions or distress, there was no evidence in place to ensure staff could manage this in a positive way that protected people’s rights and dignity and maximised learning for the future about the causes of their distress.

There was limited guidance available on how to support people in a positive way and minimise the risk of harm. People did not have accurate and detailed risk assessments in place to provide staff with guidance about how to support them safely and manage risk. People were not informed of the risks specific to them or always involved with the planning of their care.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff did not have access to detailed information about actions to ensure equipment was checked and well-maintained to deliver safe care and to keep people and themselves safe.

The service did not always ensure there was guidance to support staff in the delivery of safe care. The provider had guidance within the care records to inform staff to look out for hazards. However, staff did not have guidance available to check equipment was safe when they supported people to mobilise. For example, one person’s care plan instructed staff to check the weight of the person to ensure the weight did not exceed the capacity of the hoist. There was no guidance available regarding what this weight was, and the person was referred to as ‘patient’ within their care records.

Care records had inconsistent and conflicting information in relation to equipment people used. Staff did not have information on how to evacuate a person safely who had mobility needs and there was no risk assessment in place for the use of flammable topical creams which posed a fire risk.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not make sure staff received effective support and relevant training for their role. They did not work well together to provide safe care that met people’s individual needs. Staff did not receive the support they needed to deliver safe care. The provider was not doing all that is reasonably practicable to mitigate risks.

Systems and processes were ineffective in reducing risk when supporting people with a learning disability, autistic people and people with communication needs as not all staff were trained in these areas. There was no oversight of specialist training. For example, blood glucose training was in place for 1 member of staff. This meant people may be placed at risk if this staff member was away from work for any reason. There was no training for choking and how to meet people’s nutrition and hydration needs.

Staff recruitment files were in place along with Disclosure and barring service (DBS) checks and references. However, the service did not have records of staff interviews and there were gaps identified within the employment dates with no reasons recorded. Therefore, the provider could not be assured all staff were safe to work with vulnerable people.

Staff meeting records did not document staff’s voice to ensure that concerns raised by staff were followed up. The service did not have oversight of their spot checks and training to support staff in mitigating risk. Some staff supervisions and spot checks did not evidence follow up action support needs for staff to deliver high quality care.

Due to the poor quality and lack of personalised care plans and risk assessments, staff did not receive the support they needed to deliver high quality and safe care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had identified concerns within spot checks and observations such as, staff not washing their hands and ensuring their own cleanliness and hygiene, PPE not being worn and the daily notes were unclear.We could not be assured that the service managed infection prevention control, as these records did not contain follow up actions.

People and relatives told us staff wore gloves, aprons, personal protective equipment (PPE). We also received feedback staff walked in with muddy or wet shoes. However, staff told us they had PPE and made sure the home was clean. The registered manager told us staff came to the office to collect their PPE and for the live in staff, the PPE is distributed to them.

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. The provider did not ensure safe systems and processes were in place to ensure people were supported safely with their medication.

Care records did not contain information to support staff to ensure people were supported safely with their medication and associated risks. One person required support from staff around managing their diabetes. There was no information recorded about the risks of hypoglycaemia (low blood sugar), or hyperglycaemia (high blood sugar), information about who administered the insulin and what the normal range was for a person.

Staff did not have information regarding what topical creams were to be applied and where creams were to be applied to people. Creams were not listed on the medication administration records (MAR) charts, risk assessments and prescribed ‘when required’ (PRN) protocols were not in place. A PRN protocol should include the specific reasons/situations the PRN medicine should be administered and at what dose.

Medicines were not always being recorded as given, doses were not recorded, care notes did not record why medicines were not being taken adequately, or why medicines were not being given.

The service supported people with complex needs which require time specific medicines. Care records did not state some medicines were time specific nor what the agreed times were.

There was a risk of people overdosing as care records did not contain enough information. For example, one person was prescribed a medicine to take up to 3 times a week, however the family also supported the person with their medicines. There were no assurances or risk assessments in place to ensure the person did not receive more than the prescribed amount of medicine. MAR charts identified this person had this medicine more than 3 times in a week on two separate occasions by staff.

Medicine competencies were not in place to ensure that staff were trained to carry out safe delivery of medicines. This placed people at risk of not receiving their medicines from trained and competent staff.

The service did not carry out stock checks of medicines. There was no oversight of medicines errors or processes to ensure medicines were in place for people. The service did not have accurate, up-to-date information about people’s medicines available to staff to support safe care.