FastFallsResponse Ltd

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 newly registered 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.

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 shared lessons learned with staff team, however this was inconsistent.

The electronic care planning system used by the provider allowed staff to raise concerns whilst out in the field. These were looked at and actioned, however the provider failed to identify they did not have an overview of incidents, accidents and concerns raised. This meant they could not be assured they were able to identify themes and trends to ensure lessons were learned to continually identify and embed good practices.

The provider responded to our feedback and started to develop a new system to ensure the necessary overview and a consistent system of sharing lessons learned with staff was introduced.

People told us staff worked to keep them safe, and relatives confirmed this. People and relatives told us they felt they could raise concerns with the provider if necessary and felt they would be listened to.

Staff told us they knew how to raise concerns with the management. A staff member said, “Everyone is genuinely very caring. Complaints and concerns are treated quickly from us support workers out on the field.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Records confirmed the provider supported people with referrals to healthcare professionals when required. People told us staff were helpful and a lot of the time relatives were in charge of organising people’s health appointments.

During the inspection the provider introduced a new system to ensure that, in the event of an emergency hospital admission, ambulance crew would know who was supporting the person. This supported continuity of care, including when people moved between different services.

The provider did not always share concerns quickly and appropriately.

During the inspection the provider improved its oversight of safeguarding concerns. During the inspection, some concerns were identified that had not previously been raised through safeguarding processes. These were completed retrospectively. During the inspection the provider started to make changes to the way incidents and accidents information were reviewed and monitored. This meant the provider was in the process of strengthening its governance systems to ensure concerns were identified, escalated, and acted upon appropriately. The new governance system required time to become embedded in practice and for the changes to be sustained.

Staff told us they thought people were safe receiving care from the service. Staff felt confident raising concerns with the management team. A staff member said, “If I had any concerns that someone might be experiencing abuse or neglect, I would report it immediately to the senior member of staff or manager, following the company’s safeguarding procedures. If necessary, I would also report the concern to the appropriate external safeguarding authority or emergency services, depending on the situation. My priority would always be to ensure the person’s immediate safety and wellbeing.”

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

Records showed 1 person who displayed anxiety or distress due to their medical condition had a detailed plan and risk assessment in place. However, the provider failed to identify not all staff members were assigned the required training. This meant the provider could not be assured all staff possessed the necessary knowledge and skills to support people safely and in accordance with their assessed needs.

Some areas of day-to-day living were not risk assessed, such as people’s home environment. This meant the provider could not be assured that all potential risks to people’s health, safety and wellbeing had been identified, assessed and mitigated appropriately.

This was fed back to the provider who started to review the assessments in place.

Other risk assessments were detailed and provided enough information for staff on how to minimise risk to people.

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.

The provider had failed to identify that risks associated with people’s home environments had not been assessed. We found equipment used to hoist 1 person had been serviced and was subject to regular safety checks. However, another piece of equipment used to support people following a fall had not been serviced, and this had not been identified through the provider’s governance and oversight systems. During the inspection, the provider arranged for the equipment to be inspected to ensure it was safe for use.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Recruitment processes in place were not always followed. We found some staff employment histories were incomplete and some staff started lone working before all the required pre-employment checks in line with the statutory requirements were complete. This meant the provider had not taken all reasonable steps to ensure staff were of good character and suitable for the work they were employed to undertake.

We brought these concerns to the attention of the registered manager, who assured us this concern would be addressed with the support of an external professional experienced in the correct recruitment processes.

We found some gaps in some staff training. During the inspection the provider booked additional manual handling training and started the process of reviewing the training processes used by the service. Additionally, the provider failed to complete competency checks and staff supervision were not planned for, there was no oversight for future checks and supervisions to be completed. This meant the provider could not be assured that staff had the necessary skills and knowledge to carry out their roles.

However, people confirmed staff members had been watched and their work checked by the registered manager.

People told us they saw a small team of staff. This supported consistency and meant staff knew people well. A person said, “They go above and beyond to help. We trust them to be reliable and always willing to help.” People confirmed new staff members usually had an established staff member with them on their first visits.

People were complimentary about staff members and told us they supported them with their mobility and supervised simple tasks when required. For example, 1 person was talked through getting in and out of their bed following their decline in health. People confirmed staff members had been watched and their work checked by the registered manager.

The provider assessed and managed the risk of infection.

People and relatives told us staff worked in a hygienic way and wore personal protective equipment (PPE), such as gloves when required. A relative told us, “They always leave everything clean and tidy.”

Staff confirmed they had access to PPE.

The service had an up-to-date infection control policy in place.

Some elements of people’s medicine administration were not safe.

Staff did not have guidance to ensure medicines taken occasionally were given in a consistent way. During our inspection we identified people did not have person centred risk assessments for medicines such as blood thinners, and fire risks associated with paraffin-based creams were not assessed. Therefore, the provider could not assure themselves that staff knew what precautions to take to keep people safe.

Records confirmed people received their medicines as prescribed. The provider used an electronic care planning system which meant any changes to people’s medicines could be implemented immediately and available to staff. Allergy information was recorded in people’s care plans.