CJ Noah Healthcare

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 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.

The service was in breach of legal regulations in relation to people’s safe care and treatment and safe staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety. Risks to people were not always used to learn and improve.

Care plans and risk assessments were not updated or reviewed following an incident. There were no systems in place to share information with staff following an incident, accident or change in someone’s needs. This placed people at increased risk of harm.

Concerns recorded on a notification to external stakeholders were not logged on the provider’s safeguarding, incidents or complaints log to evidence the actions taken.

However, staff knew the process to follow if there was an accident or incident and said when they reported concerns to the registered manager they were listened to, and action was taken. Following a medication incident there was evidence of post incident analysis and a record of the lessons learnt.

The service did not always have effective processes to support safe systems of care. For example, care plans lacked information about people’s communication needs, what was important to them and how and when to support them. The registered manager explained the discharge planning process when someone was in hospital including liaising with healthcare professionals and staff told us they had the opportunity to get to know people they were supporting before providing care on their own. However, there was no evidence of these processes.

Care plans did not contain important information to help staff keep people safe. For example, 1 person’s care plan stated they were unable to communicate the things they may need, but the communication care and support plan were not completed.

The provider did not always 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 always share concerns quickly and appropriately. For example, following safeguarding concerns identified by staff the provider did not inform the local authority until prompted by a social care professional.

However, people and staff told us they felt empowered to raise concerns to the registered manager. Staff had received training and understood people’s human rights.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

One person’s care records stated they were at risk of malnutrition; however, their nutrition and hydration care plan was not completed meaning staff did not have information on how to manage the risk. It was also stated that they were at risk of falls, but no falls risk assessment was in place.

Where people had a long-term health condition there was not always a risk assessment in place, and care plans lacked sufficient detail to enable staff to understand and mitigate any associated risks.

The provider did not always complete an assessment of risks in people’s homes which could impact upon people and staff before the support commenced. For example, risks relating to fire safety, access and room temperature.

The provider was introducing a new template to capture information about people’s environment and equipment. We will check for improvements at our next inspection.

Staff told us they respected people’s homes. One person said, “They always leave my home clean, tidy and how they found it.”

The provider did not carry out robust and safe recruitment checks to ensure that staff were suitably experienced to carry out their role. The provider did not always make sure staff received effective supervision and development.

They did not ensure staff had an induction programme that prepared staff for their role.

At the time of the assessment the provider had staffing shortages which they said they were urgently addressing. However, this meant that people did not receive consistent care, and staff did not have sufficient breaks.

Staff acknowledged there were staffing challenges but provided reassurance that people were safe. Staff said they had regular discussions with the registered manager for support and to discuss any concerns or changes in people’s needs.

People provided positive feedback about staff skills and experience.

The provider did not always assess or manage the risk of infection.

Infection prevention and control (IPC) risk assessments were either not in place, or they were incomplete and not person specific. This meant that staff did not have information about people’s risk of catching or spreading an infection and how to support their safety.

However, people told us “The [staff] wear plastic aprons and they wear gloves which are disposed of after use. [Staff member] will ask me if I would like them to put the rubbish out for me.”

Staff understood the IPC policy and procedures, said they had enough personal protective equipment (PPE) and they had completed IPC training.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

At the time of the assessment the provider told us no one was being supported to manage their medication. However, care plans for 2 people stated that they required verbal prompts to take their medication. There was no medication administration record in place, no risk assessment in place and the care plan did not provide information to staff on how to support people with their medicines safely. Medication audits had not been completed as per the provider's policy.

However, staff had received medicines training, and their competence would be assessed in the event they administered medication.