Chadcome Healthcare 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 people’s safe care and treatment and the ways people’s medicines were managed.

This service scored 56 (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 a positive culture of safety. The service was small and there had been no adverse incidents to learn lessons from. The nominated individual shared instances in their career within the care sector, where lessons had been learned from incidents and discussed scenarios of where they would be applied at Chadcome Healthcare Limited. These included escalating concerns to relevant health and social care professionals, discussions with staff and revisiting risk assessments if needed.

The provider did not always work with people and healthcare partners to establish and ensure there was continuity of care, including when people moved between different services. Initial assessments were completed before people’s support commenced, care was planned with people and where needed, their families. The nominated individual shared an example where they had worked with NHS staff to maintain a continuity of support for a person. Information about people was not always accessible to emergency personnel if needed. The nominated individual told us they were working on a ‘hospital passport’ in the event where a person may move between services or require a hospital admission. This was to support a continuity of care for them.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had completed safeguarding training and knew how to escalate concerns externally. A staff member told us, “If I was worried about safeguarding, I would raise a complaint to [nominated individual], fill in an incident form and complete the notes. If needed, I would go to the safeguarding team myself. Better to report than not report.” People told us they felt safe with staff. One commented, “I am safe with the staff, if I was worried I would move to another agency.”

The provider did not always work well with people to understand and manage risks. Staff mostly provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. However, risk assessments lacked information to mitigate potential risks to people. For example, a person was prescribed anti-coagulant medicines which posed a risk of bleeds in the event of an injury. Their care plan and risk assessment did not contain sufficient detail on what staff should do in the event of an accident. People’s falls risk assessments were not always robust and did not contain all information required to establish the risk level and how to reduce it. This included where a person experienced leg swelling, there was no documented detail in how to prevent the swelling, such as, to support them to elevate their legs and to administer the medicines as prescribed. Although the documentation lacked detail, staff were supporting the person with these actions. We discussed our concerns with the nominated individual who confirmed they would review all risk assessments as a priority.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Initial assessments considered environmental risks and equipment needed. The nominated individual gave examples where environmental risks had been mitigated for people, for example, they suggested a pathway to be levelled for a person so they could safely leave their house. Other examples included suggestions to remove rugs as potential trip hazards.

The provider did not always ensure robust recruitment processes were followed. Staff recruitment records were not fully complete. The nominated individual was unable to provide interview records for staff and details of how they assured themselves of staff’s character and conduct from previous employers. The nominated individual made sure there were enough qualified, skilled and experienced staff who worked together well to provide care that met people’s individual needs. People told us staff were usually on time and stayed for the allocated amount of time. One person said, “On the whole I am happy with punctuality, if they are late its often out of their control.”

The provider assessed and managed the risk of infection. People told us staff supported them to keep their homes clean and tidy. People’s care plans contained domestic task which required completing. Staff had access to appropriate personal protective equipment (PPE) and had completed food hygiene and infection prevention and control (IPC) training.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medication administration records (MAR) charts were incomplete and did not contain the required information for staff to safely support people with medicines. Gaps of information included dates of the medicine cycle, the name of the prescriber, the strengths and doses of medicines. Some medicines were administered on a ‘when required’ (PRN) basis, however, there were no protocols to support staff’s decision making in when to offer the medicine. People’s care plans also lacked this information and were not consistent with the medicines listed on the MAR charts. A person’s medicines were contained in a blister pack, which meant all medicines had been dispensed together, the MAR charts did not individually list the medicines so staff could not be assured of what they were administering. We raised our concerns with the nominated individual during our inspection; they accepted the shortfalls and sent us much improved MAR charts.