Clarity Homecare Wolverhampton

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 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 people’s safe care and treatment, including medicines management and staff training.

This service scored 38 (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. Lessons were not learnt to continually identify and embed good practice.

The registered manager and the nominated individual confirmed there were no systems in place to ensure lessons could be learnt and improvements made to the service where needed. They were unable to provide any evidence to show how learning was considered. The registered manager and the nominated individual told us no incidents had occurred at the service. However, we found 1 incident form had been completed in relation to a fall. Other than informing the relatives and contacting the emergency services, there was no evidence to show action had been taken following this incident and there was no care plan or risk assessment in place that had considered this risk.

The provider did not ensure, establish and maintain safe systems of care.

There were no records in place to show people’s assessed needs and risks. The registered manager told us they went out and asked people and relatives some questions before they started using the service. They then completed the care plan based on these questions. Other than for 2 people, there were no ‘question forms’ available for the people that were currently supported, as the registered manager told us they ‘destroyed’ them once the care plan was completed. Therefore, it was unclear what people’s needs were and how any needs and risks were identified and planned for. This meant we were not assured people’s needs and risks had been accurately assessed and planned for, placing people at risk of receiving unsafe or unsuitable care.

Following our inspection we told the provider to take action to keep people safe. The provider sent us an action plan outlining how they would do this, we will review this as part of our next inspection.

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 registered manager, the nominated individual and staff did not fully understand safeguarding procedures. With 1 staff member telling us, “They would keep things secret.” And another staff member explained the process as, “Human rights and privacy.” Staff were unable to confirm if they had received training in this area, with 1 of the staff we spoke with confirming they had not. We requested evidence that staff had completed training in this area. However, the training matrix we received did not cover safeguarding training.

However, we saw there was a safeguarding process in place. We did not see any information documented which placed people at risk of potential abuse that had not been reported. People told us they felt safe being supported by staff. One person said, “I have 2 calls a day, 1 in the morning and 1 at teatime, I feel safe in the carers company I wouldn’t have them if I didn’t.”

Following our inspection we told the provider to take action to keep people safe. The provider sent us an action plan outlining how they would do this, we will review this as part of our next inspection.

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.

Other than for the environment there were no risk assessments in place for people. Care plans for 2 people identified a history of falls. There were no records in place to show the needs associated with their history of falling had been assessed and planned for, and no guidance was recorded to ensure staff managed this risk in a safe and consistent manner. This placed these people at risk of receiving unsafe and inconsistent care.

One person’s daily notes showed they regularly experienced periods of emotional distress, including times where they were verbally and physically aggressive towards staff and non-compliant with personal care tasks. There were no records in place to show this person’s needs associated with their emotional distress and non-compliance had been assessed and planned for, and no guidance was recorded to ensure staff managed these needs and risks in a safe and consistent manner. The information staff told us confirmed they were supporting this person in an inconsistent way during these times. This placed this person and staff at risk of harm.

The registered manager told us another person sometimes had 2 staff for calls and sometimes had 1 member of staff. They told us 2 staff were needed for personal care. Staff and daily notes confirmed this person received personal care and support to transfer to and from the commode when only 1 staff member was present. The care plan and risk assessment in place did not state the number of staff that were needed to support this person to safety transfer or deliver safe personal care and there was no assessment of their needs in place for us to review. This meant we could not be assured this person’s needs and risks had been accurately assessed and planned for, and we could not be assured they were receiving safe care.

Following our inspection we told the provider to take action to keep people safe. The provider sent us an action plan outlining how they would do this, we will review this as part of our next inspection.

The provider detected and controlled potential risks in people’s home environments.

People had individual risk assessments in place that related to their environment. This covered any risks staff may face in people’s homes. This information was available for staff so they were aware of any risks that maybe present. Staff confirmed they had seen these plans.

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.

Staff were not always able to confirm which training they had received. With 1 staff member telling us they had not had any training, despite working at the service for over a month. We asked to review training records and were provided with a training matrix after our site visit. This only identified 3 of the 10 staff that were employed and all of the training for these 3 staff members had expired. There was no reference on the training matrix to show staff had received training in; medicines management, safeguarding, mental capacity and consent or moving and handling. This meant we were not assured staff were suitably skilled to safely support people.

After our inspection we received an updated training matrix which we will review as part of our next inspection.

There were no systems in place to monitor calls times to check care was provided at the agreed times.

However, people and relatives were happy with the timing of their calls with 1 relative telling us, “The carers timekeeping is prompt, we had a trial weekend first to see if it would work and since then everything has been working well and we have 2 carers which alternate, this was important to me.” We viewed rotas which confirmed staff were allocated to people’s calls in advance.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

The provider assessed and managed the risk of infection.

People and relatives told us staff wore Personal Protective Equipment (PPE).

Staff confirmed PPE was available. One staff member told us, “I have gloves and aprons I use for personal care and put them in the correct bin after.” There were processes in place to ensure staff protected people from the risk of cross infection.

The provider did not always make sure that medicines were managed safely.

The registered manager and the nominated individual told us and records confirmed staff/the care company were not responsible for administering 1 person’s medicines, the family were. However, daily notes and staff confirmed they were administering ‘tablets’ to this person. There were no care plans, risk assessments or administration records in place in relation to these ‘tablets’. This meant the risks associated with this person’s medicines had not been assessed and planned for, placing them at risk of harm through not receiving medicines in a safe and consistent manner.

Another person had no reference to them being prescribed Paracetamol in their care plans or medication administration records. Staff and daily notes confirmed Paracetamol was administered to this person on an ‘as required’ basis. There was no care plan, risk assessment, administration record or ‘as required’ protocol/guidance in place for this medicine. This placed this person at risk of harm through not receiving this medicine in a safe and consistent manner.

Other people were also prescribed ‘as required’ medicines. There was no guidance in place for these people which showed when these medicines should be administered. This placed these people at risk of receiving ‘as required’ medicines in an unsafe and inconsistent manner, placing them at risk of harm.

One person’s medicines administration record confirmed they were prescribed Paracetamol twice a day. There was no other information recorded, including that a 4 hour gap was required between doses in line with manufactures guidance. The medicines administration records showed a 4 hour gap was not always present. This placed this person at risk of harm from receiving too much Paractetamol within a safe period of time.

A person was prescribed a patch to be administered weekly with the instruction to change the administration side. There were no records to show the side was changed or where this patch was administered. This placed the person at risk of not receiving their medicines safely and in line with the prescriber’s instructions.

The medicines administration record showed this patch was administered 3 times rather than the prescribed once only administration for 1 week. The registered manager and nominated individual were not aware of this during our site visit. After our inspection they provided us with an investigation which showed this was a documentation error, however other than speaking to the staff member there was no supporting evidence to confirm this was the case. Not effectively investigating medicines incidents, placed this person and others at risk of harm from the risks associated with medicines.

There were no audits of medicines in place. Not having effective systems in place to ensure the safe management of medicines placed people at risk of harm from the risks associated with medicines. For example, receiving too much or too little of their prescribed medicines.

Following our inspection we told the provider to take action to keep people safe. The provider sent us an action plan outlining how they would do this, we will review this as part of our next inspection.