Vintage Revelations Gloucestershire

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.

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

This service scored 53 (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 always ensure there was a proactive and positive learning culture.

There were processes in place for staff to report and record incidents which were reviewed by the registered managers. Records showed actions had been identified after incidents; however, there was limited evidence they had been acted on, and people’s associated care and risk management plans had not been updated.

Staff were clear about their responsibilities to report any concerns or incidents. However, we received mixed views from staff on whether they received updates or lessons learned from incidents. Some staff stated there was no formal system to reflect or update them on the outcome of incidents or changes in people’s care needs. One staff member said, “We only get told updates if we ask.” Whilst other staff felt they were mainly informed of changes in people’s care needs. However, other staff said they had been updated after incidents.

The provider’s data management systems provided the registered managers with real-time information about the delivery of people’s care. However, the actions taken were not always documented promptly to show risk mitigation and continuous improvement.

The registered manager completed a yearly analysis of incidents; however, this frequency may prevent the timely identification of significant trends or patterns of concern.
 

The provider did not always effectively work well with people and healthcare partners to establish and maintain safe systems of care.

We were not fully assured that safe systems were in place to support people to safely transition into the service in an emergency. The registered manager explained most people using the service had been referred by the local authority and on occasions they had been asked to provide a package of care to people in an emergency. Managers explained they requested as much information as possible to understand people’s needs which was followed up with the person and/or their relatives as appropriate, to inform the package of care and care plan.

Some staff reported significant information about people’s personal and support requirements were not always recorded in a timely manner. However other staff felt they had the information they needed to support people.

Some people and relatives said a follow up assessment of the person’s needs had not been completed with them when they had left hospital, and they had not been given an opportunity to review their care plan and discuss their needs.
 

The provider did not always effectively work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Improvement was needed in the provider’s safeguarding management systems to notify CQC and to demonstrate the actions which had been completed to help mitigate future risks to people. Staff were aware of their role and responsibility to report safeguarding concerns. Safeguarding concerns were raised appropriately and referrals made to the appropriate safeguarding authorities.

We found the service did not always use the principles of the Mental Capacity Act 2005 (MCA) when supporting people who lacked capacity.

People and their relatives reported feeling safe with staff. We received comments such, “[Name] feels safe with them, he is comfortable with the carers” and “She totally trusts the carers she has and is very safe with them.”

Staff had received training in safeguarding and were supported to understand the importance of recognising types of abuse and reporting any concerns. The provider had produced safeguarding leaflets for staff to reinforce the provider’s safeguarding policies and training.
 

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.

People’s care records did not provide staff with explicit guidance on how to mitigate people’s personal risks such as reducing the risk of skin breakdown, choking and falls. We found people’s support requirements and personal risks had mainly been identified and recorded. However, there was not a consistent approach in ensuring people’s care records were accurate and complete to guide staff in how to manage and mitigate people’s personal risks.
Nationally recognised risk assessment tools were used to identified people’s level of risks such as risk of skin break down or malnutrition. However, there was limited evidence of the action taken when the level of risk had been identified as a higher risk.

There was not a consistent approach in updating all areas of people’s care records. For example, when people’s needs had changed or incidents had occurred, the registered managers had not ensured people’s care records were reviewed to identify areas of learning, and changes in people’s support needs to improve their safety. Systems to review staff daily care records had not been effective in identifying changes in people’s needs. For example, for one person, staff had recorded they had applied medicinal creams due to emerging skin breakdown; however, this change in their skin integrity and the application of creams had not been updated in their care plan.

Staff reported mixed views on their access and quality of people’s care records on the provider’s electronic care management system. We received comments such as, “Can't say I have seen many risk assessments on the file, I wouldn't know where to look.” However other staff said comments such as; “We look on the care plan, it has different sections, there is one for risk assessments. It will tell you if there is risk to yourself or the client. We check them regularly. We can update the risk assessments ourselves in the office or ask the office to do this.”

Some people’s relatives expressed concern they had not seen or been involved in the assessment of people’s care needs to enable them to give an accurate reflection of people’s personalised support requirements. This was raised with the registered managers who explained people or their relatives could access their care records on the providers electronic care management system; however, they were unable to demonstrate how this was monitored or offered to people. We received mixed views about peoples and their relative’s access to the system. One relative said, “We can look at the App and dad can see which carer and the time they will come. It works well for us.” However, others reported the system was unreliable. One person said, “They have an App which tells you who is coming and when, but they don’t update it with changes, or it doesn’t update properly so it isn’t really very reliable.”

Feedback from staff, people and relatives raised concerns about inconsistent and delayed care call times, which compromised people’s safety and left people at risk of unmet needs. For example, some people’s toileting needs were not effectively managed due to the variable intervals between care calls. Systems to ensure people’s care was delivered by their preferred gender of staff were not always effective.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider completed environmental risk assessments and assessed the risks to staff who worked alone in people’s houses. Staff raised no concerns about their safety. The registered managers agreed to review their lone working risk assessments to reflect specific risks posed to staff when they worked in people’s homes. For example, risk assessments for people who have pets had not been assessed.

People and their relatives told us staff mainly operated their equipment safely.

The provider did not always make sure people receive their care calls in a timely manner.

We received mixed feedback and concerns from people and their relatives about the timings of their care calls and being supported by a core staff team who were familiar with their needs. Some people and their relatives raised significant concerns about the reliability of their care call times. We raised this with the provider who told us people were mainly supported under a ‘block hours contract’ which enabled staff to be flexible and responsive to people’s needs. However, the impact of this model on people who required regular and time specific care had not been fully considered by the provider. This had resulted in people receiving care at various times and by a large staff team who were not always familiar with people’s needs. We received comments such as; “The early morning call can be a bit random – I asked for 6.30am but sometimes it can be 8am or 9am. Their timing isn’t good”; “Their timing is poor” and “We requested a time of 10am but the times varied between 7am and 12 midday.” Another relative explained, “We have 2 carers 4 times a day and it’s all a bit variable.” They went on to say, “The times are all over the place, take today, they came at 8.30 am and they are back now at 11.30 am to give [relative] lunch. That’s no good.” However other people provided positive comments such as, “I have regular carers coming in, people that I know, and they never send 2 new carers together”; Usually the morning carer comes at lunchtime and then different ones for the other calls. I think we have a little group of about 5 carers, and they are good and then others fill in” and “I do have some regulars but a lot of random ones too.”

We received mixed feedback from staff regarding the planning of their care call rota. Some staff told us their care call schedule could be changed with limited warning. Other staff explained on occasions they felt rushed and travel time was not always factored into their care call rotas which impacted on their breaks and rest time. We received comments from staff such as: “I do not have enough time to travel between calls. They do not take that into consideration when there are road works or bad weather. I have complained about my manager lots of times already”; “I don’t think I have enough time between calls. I have fed this back, but it usually happens on days when we have lack of staff, so we have to do more calls than normal.” Another staff member said, “They do not give enough travel time at all. They give us 10 minutes to get from one side of Gloucester to another.”

The provider had a training programme including classroom based and online eLearning to ensure staff received training relevant to their role. Staff mainly felt well trained and supported by their colleagues and managers. Staff were required to complete a 3-day induction course and workbook, followed by annual refresher courses. We received comments from staff such as, “I think the training they provide is well equipped and very useful. It is face to face. They let us know when we require refreshers. Yes, they provide additional support for us.” Whilst most staff said they felt supported, some staff shared there was an inconsistent approach of supervision meetings during and after their probation period. The provider acknowledged their monitoring systems of staff training needed to be clear to demonstrate the courses covered by the training programme.

Most of the comments we received from people and their relatives regarding staff skills and training were positive; however, some relatives expressed concerns about staff’s understanding of supporting people who live with dementia and supporting people with specific dietary needs.

The provider had identified some shortfalls in the recruitment checks of staff when they had transferred to the provider under the ‘Transfer of Undertakings (Protection of Employment)’ (TUPE) framework from another employer. TUPE protects employees' employment rights when they transfer to a new employer. However, there was limited evidence the identified gaps in staff recruitment files had been addressed and acted on in a timely manner.
 

The provider always assessed and managed the risk of infection.

Staff told us they had access to personal protective equipment (PPE) and had been trained in infection control and using PPE appropriately.

Relatives told us staff maintained good hygiene practices and changed and used the correct PPE appropriately during people’s care calls. However, one relative felt there was not always a consistent approach and said, “They usually use their PPE, but some don’t.”
 

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

People’s care plans did not always contain information on how people liked to take their medicines, reasons for the prescribed medicines or information to support staff with the administration of “as required medicines” such as painkillers. Protocols were not in place to direct staff on the safe administration of ‘as required’ medicines. For example, we found some people’s ‘as required’ medicines had been administered regularly without escalating this to the clinical prescriber. The provider had not recorded the risks and agreed control measures when people self-medicated or where there was shared responsibility in managing people’s medicines

Body charts and clear guidance on the dosage of creams were not always in place to guide staff on the application of creams for people who required skin protection. Risk assessments were not in place for paraffin-based creams.

People’s medicine administration records (MARs) were not always accurate and complete. Staff had recorded several inconsistent codes on people’s MARs for the reason people’s medicines had not been administered.

The irregularity of staff care call times had impacted on the administration of people’s medicines especially for those people who required regular intervals between the administration of their medicines such as pain killers in line with their prescription.

The shortfalls in the safe management of people’s medicines had not been identified by the provider’s own monitoring systems.

Staff told us and records showed staff had been trained in the safe management of people’s medicines and their skills to administer people’s medicines safely had been assessed. For example, one staff member said, “Yes, I have completed medication training, and we get checked on this.”