Archived: My Homecare Reading 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.

The provider was previously registered at a different address. The rating at the previous address was Inadequate.

At this assessment the rating has remained 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 people’s safe care and treatment, safeguarding, staffing and notifications.

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 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.

There was a lack of oversight and monitoring of incidents. Incidents and accidents had not been effectively and robustly reflected upon to drive improvement. For example, incident forms documented people had come to harm. One person had sustained multiple bruising and skin tears. These forms had not been reviewed or investigated to ensure people were protected from the risk of harm reoccurring. Information did not document what action was taken if any, following accidents and incidents.

Incident forms were not available to staff as they were kept in the office. Care plans and risk assessments had not been updated to reflect people’s needs following incidents.

People and their families told us “If I raise a concern I’d say I’m brushed off at best” and "It feels like we are not listened to when we raise concerns."

The registered manager told us there were no lessons learnt in place. Records needed to effectively detail, review and monitor incidents. This meant opportunities to learn lessons from incidents and take appropriate action were missed.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

People’s care and support was not planned and organised with people, partners, and communities to ensure continuity. People and their relatives told us, “They haven’t been out to assess [person] since [person] was released from hospital."

Information within people’s care plans was not a reflection of their current needs. This would not ensure important information could be shared with other professionals, such as during hospital visits. The approach to identifying and managing people’s risks was not proactive as records had not been updated to accurately reflect people’s needs or were not in place.

A relative told us, "One day [person] had fallen off [their] chair and the carer didn’t wait for the ambulance to take [person] in”

The views of people who used the service, relatives, and staff were not always listened to or considered. Where people were supported by external services, risks identified by professionals and transitional documentation had not been used within people’s care plan and risk assessments.

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 provider did not share concerns quickly and appropriately.

Systems in place were not effective at ensuring people were protected from abuse and neglect, the provider had not identified people were at risk of neglect and failed to demonstrate a strong understanding of safeguarding.

Incidents were not reviewed adequately, and safeguarding concerns were not always raised. There was no oversight of safeguarding’s raised to evidence the action taken to keep people safe. We were not notified about safeguarding alerts by the service as the registered manager was unaware of their responsibilities to notify the commission.

Staff were not always aware of how they would raise safeguarding concerns. Staff we spoke with told us, “[I would] report to senior and the management if they were available, if it was physical I would inform manager, I would try to act as quickly as I can.” Another member of staff did not understand who they should escalate concerns to if the manager was not present, or if they were unable to tell the registered manager.

Staff told us they did not always have access to the safeguarding policy, had not seen it or signed it. The registered manager provided evidence policies were sent to staff, however, there were no assurances sought that staff understood this information.

People and their relatives told us they did not always feel safe. We heard, “I’m worried for [person’s] safety”, “There is a real risk that people who are more vulnerable than my [person] would come to harm” and "It can feel unsafe when carers don't complete the visit properly."

During the inspection we found examples where people were put at risk of ongoing harm of abuse, the registered manager had not identified these concerns, therefore had not raised them with the local authority, or taken action to ensure people were safe. Where the registered manager had raised concerns about people’s welfare with other professionals, advice given to the registered manager was not documented as being followed.

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.

Risks associated with people’s care had not always been assessed, identified or managed to ensure people received safe care. The provider failed to ensure assessments and guidance was in place to mitigate risks relating to people’s health needs. For example, there were no risk assessment or guidance in place for people who required support around, skin integrity, nutrition and hydration, seizures, mobility, diabetes, falls and refusal of care.

Care plans outlined people’s medical conditions, however’ the provider had not implemented any guidance for staff to support people with their health conditions on a day-to-day basis or in an emergency situation.

Staff did not always feel they had the guidance in place to support people and their needs. One person required support with equipment to reposition. This guidance was not available to staff within the care plan. Some staff told us they had to ask families on how to ensure the person was correctly positioned, others told us this guidance was sent to them through the use of WhatsApp.

People were not involved in their care planning. People and their families told us, “I don’t think there is a care plan but if there is I haven’t seen one” and “The care plan was put in place at the start, but we’ve only ever done that one and it has never been refreshed, we don’t really get to see it either."

The provider did not always detect and control potential risks in the care environment.

The provider failed to ensure they carried out adequate assessments of people’s homes to ensure any environmental risks were mitigated.

Information in care plans was not clear around what support was required with people’s environment to keep them safe. For example, the ambulance team raised concerns around one person’s environment, this was corroborated by staff within daily notes. This information was not included within the care plan and there were no risk assessments in place to ensure the risk was mitigated.

Fire risk assessments were not in place. Documentation made no mention of a zero-base cream being used and the risks associated with emollient creams in terms of fire and smoking. This is because some emollient creams are highly flammable, placing people at increased risk in a fire.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider did not have an effective way to monitor care calls to ensure staff had enough time to deliver care based on people’s care needs. This resulted in care calls being missed or delivered at inappropriate times.

Staffs’ rotas were subject to change, and people were not sent a rota in advance. Staff we spoke with told us they worked long hours and were exhausted. Staff we spoke with said “Sometimes there is not enough time to do calls. Some clients do not have enough time in their call, so staff “prioritise”, if one client’s condition is not as bad as another, I will report it to the manager.”

We spoke with people and their relatives, we heard, “Sometimes it feels like the rota changes without notice or prior warning”, “The rota isn’t always sent out so we never know who is meant to be coming” and "Rota is by word of mouth, I’ve asked for a rota but never get one."

There was a lack of oversight in place to ensure staff were suitably trained. The training matrix evidenced not all staff were adequately trained, some staff started employment with training from previous employers and did not complete the services mandatory training. Staff said they had completed training from their previous employment and struggled to complete the services training as they only have one day off a week.

Competency assessments such as medicines, had not been completed to ensure staff were performing in line with safety standards.Not all staff had received training in diabetes management, catheter care, and epilepsy. Some staff had good knowledge of people’s needs; however, several staff we spoke with were unable to explain what they would do to support people with specific training needs.

People and their relatives were not assured staff had received effective training. We heard, “I’d say training is non-existent” and “One or two carers are well trained, most carers need more training and guidance."

Staff were not always recruited safely, there was insufficient evidence to demonstrate the staff employed were of good character, had the qualifications, competence, skills and experience which are necessary for the work to be performed by them. Staff files contained inconsistent information around dates of employment. Application dates were documented as being received after their start dates, staff carried out shadowing prior to interview dates and receipt of their safety checks.

Spot checks were carried out by the care-coordinator. Within one spot check, there were concerns noted around the member of staff’s uniform and timeliness. Spot checks had not always been reviewed by the registered manager, and no action was taken, this resulted in the same concerns occurring on future spot checks.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Relatives we spoke with told us, “Carers wear masks when washing [person]."

Staff gave good examples of infection prevention and control and had access to PPE.

Spot checks were conducted which monitored if staff were using the correct PPE and hand washing techniques.

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 failed to ensure that medicines were managed safely. The provider had not carried out competency assessments to ensure people were being supported by staff who had received adequate medicines management training.

People’s care planning documentation contained conflicting information about the level of support required with their medicines. For example, for one person, the care plan documented they required support with the medicines, there was no further information about what support was required. Other parts of the care plan documented they carried out their own medicine administration. Daily notes evidenced staff were administering medication for this person without the appropriate training or MAR chart in place.
Care plans documented some people had creams, there was no further information available on MAR charts or within the care plan about where to apply creams. For one person, their care plan directed staff to apply creams to maintain good skin integrity, there was no risk assessment in place, daily notes did not evidence staff administered creams and there were no creams listed on the MAR chart.

Some people were supported to take medicines by both staff and their families; there were no risk assessment in place to mitigate the risk of overdose. Where people had allergies to medicines, there was no supporting risk assessment in place.

Relatives told us, “One day [person] hadn’t been given [their] medicine. I think [staff] put on the app [they] had [their] medicine, but it was still in the box so they couldn’t have done. [Staff] had messed up the dossett box and didn’t know how to follow it.” We also heard, “Medication errors would be a serious worry for me, so I check everything."

The service did not complete stock checks and there were no PRN (when required) protocols in place, this meant staff did not have access to guidance which outlined the risk and need for when required medicines. The registered manager was not aware of what a PRN protocol was.

The service had a medication policy in place, which documented consent must be obtained and recorded on a medication risk assessment. Care notes did not document consent had been obtained, most people we reviewed did not have a medication risk assessment in place.