Archived: Nwando Domiciliary Care

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. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

The service was in breach of legal regulation in relation to the management of medicines.

This service scored 62 (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 have a proactive and positive culture of safety based on openness and honesty. Though staff were aware of the provider’s reporting policy and procedures and the importance of reporting concerns and safety incidents at the earliest opportunity, this did not routinely happen in practice. A member of staff failed to alert the provider and leadership team of an incident whereby professional boundaries, conflict of interest and a breach of confidentiality were crossed. The same member of staff failed to alert the provider and leadership team when a person using the service’s health had declined and emergency healthcare support had been sought.

Lessons were not always learnt to continually identify and embed good practice. Staff records, including supervision and internal investigations recorded concerns about some member of staff's performance and practice. Although actions were cited to address this, there was a lack of information to demonstrate this had been completed. Three staff files viewed demonstrated staff required additional training as a result of poor performance. Revised staff training information provided to the Care Quality Commission after our onsite assessment evidenced this had not been followed up and provided. The impact of this meant without learning from events, staff may continue to lack the necessary skills and knowledge to prevent future recurrence and inappropriate care for people using the service. Following our assessment the provider wrote to us, providing us with a copy of their Service Improvement Plan and Incident Analysis Report for medication. Both documents provided evidence of the provider's lessons learned processes.

Although the above required further development, relatives confirmed where issues for improvement were required, actions had been taken by the domiciliary care service to improve and lessons learned. For example, a relative advised of occasions whereby earlier calls by staff had not always happened to enable their family member to attend hospital appointments. The relative stated this had been raised with the service and since then this had improved.

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.

The registered manager told us about their referral and assessment process. This involved an initial assessment being completed by the Local Authority and then forwarded to the domiciliary care service. The information together with an additional assessment completed by the service was used to inform people’s individual support plan and associated risk assessments. Support plans implied people using the service and those acting on their behalf had been involved with the assessment process.

The service collaborated with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

People using the service and relatives told us they had no concerns about theirs or their family member’s safety. Comments included, “I do feel safe with the staff, they appear to be well trained on how to use the equipment they need to use in order to support me”, “Yes, [family member] does feel safe with staff and they chat away to them and vice versa. They always scramble the code for the key safe before leaving, ensuring the house is secure” and “We [person using the service and relative] feel safe.”

Staff were able to tell us about the different types of abuse and what to do to make sure people were protected from harm. Staff told us they would escalate any concerns to the provider, registered manager, Local Authority or Care Quality Commission. A member of staff told us, “If I ever suspected abuse, I would report it immediately to my line manager or the safeguarding lead. The management takes all reports seriously.” The provider was aware of their responsibility to notify us and the Local Authority of any allegations or incidents of abuse. Internal safeguarding investigations and reports were robust.

The provider ensured all risks to people’s safety and wellbeing were identified and provided enough detail as to how these risks should be mitigated.

Risks to people's health and wellbeing had been assessed and each person had personalised risk assessments, which identified the risks they could be exposed to, and the support needed to minimise these and to ensure their safety. The risks primarily related to people’s moving and handling needs, environmental dangers and medicines management, but also included those risks posed concerning specific healthcare conditions, such as diabetes, epilepsy and stoma care.

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

Robust environmental risk assessments were conducted. These are crucial to ensure the safety of people and staff by identifying, evaluating, and mitigating potential hazards in the home environment. For example, trip hazards to help create strategies to minimise the risk of falls, equipment utilised and potential security concerns. People and relatives spoken with told us they felt safe when staff visited. A person said, “I have a key safe, the staff let themselves in. On their last call at night, they check the windows and doors.”

Suitable arrangements were in place to monitor staffing levels, including shifts that were unallocated due to staff annual leave, sickness or unplanned circumstances. This ensured there were sufficient staff available to meet people’s care and support needs. On-call arrangements were effective, offering support and advice to staff where problematic circumstances were encountered.

However, people’s and relatives’ comments relating to staffing levels were variable. Where these were positive, these included, “There is a team of about 4 staff, they always let me know if there are going to be any changes or if they are going to be late”, “Staff stay the allotted time” and “The service ensures [family member] has the same staff as they find different staff hard to deal with. My [family member] knows their regular staff really well and when they are off, they send another member of staff whom they know.”

Where comments were less favourable, this related to not all people using the service having a consistent team of staff providing support. Not all staff stayed for the scheduled time agreed with the service. This impacted on the quality-of-care people received. For example, a relative stated their [family member] had experienced difficulties with a specific aspect of their care and having ‘time specific’ medication administered on time as a result of staff arriving late. Another relative told us, “Timings are very much hit and miss”, citing the morning call should be 8.30am for their family member, but on occasions staff had arrived at 10.00am and the lunchtime call should be at 12.30pm but it could be 2.30pm to 3.00pm on occasions. Where people were rostered to have 2 members of staff providing support at each visit, people told us they did not always arrive together to commence support. A relative told us, “[Family member] should have 2 staff but occasionally, 1 arrives before the other. Sometimes the other staff member can arrive 30 minutes later. The first member of staff has usually, with my help, almost done all that is needed.”

A member of staff told us, “Staffing levels are good, and the office [Nwando Domiciliary Care] ensures the rosters are planned realistically. I usually have enough time to travel between calls, and the scheduling team is understanding if there’s ever traffic or a delay. If I ever anticipate being late, I immediately inform the office or contact the person using the service.”

Staff recruitment records demonstrated most relevant checks were completed before a new member of staff started working at the service. However, not all references were from the employees most recent employer. This is important to verify the employee’s recent performance, skills, work ethic and to assess their fitness for the role. Where newly employed staff had completed their probation period, documentation providing a clear, verifiable record of performance, feedback, and any agreed-upon next steps was not routinely recorded or available.

Most staff had received mandatory training in line with the provider’s expectations using both face to face and eLearning approaches. However, 8 members of staff had only completed between 50% and 75% of required mandatory training, the rest being out of date. Not all training was embedded in staff’s day-to-day practice. A staff member’s supervision record referred them needing to improve their practice when engaging with people who were living with dementia and when supporting people to have their moving and handling needs met. Staff competency assessments were not routinely completed to ensure staff remained competent following training, for example, in relation to moving and handling, stoma and catheter care. Competency assessments are crucial for verifying and embedding staff’s skills and knowledge.

Newly employed staff received an induction and were given the opportunity to ‘shadow’ more experienced staff to ensure they understood their roles and responsibilities. A member of staff told us, “I received a thorough induction which included shadowing experienced staff, completing online and ‘in-person’ training, and being introduced to the organisations policies and procedures. The induction helped me understand the expectations of the role.” A record was not always maintained to demonstrate their progress and the outcome of ‘shadow’ shifts completed to evidence their probation period had been satisfactory.

Staff received formal supervision and ‘spot visit checks’ at regular intervals. The latter is where the provider’s representative can observe a member of staff as they go about their duties to ensure they are meeting the organisation’s values, standards and expectations. A member of staff told us, “These are positive and constructive, they give me a chance to discuss challenges, share feedback, and get encouragement.” However, improvements were required to ensure where performance issues were highlighted, evidence of monitoring and actions taken by the leadership team to address this in a timely manner were recorded. The supervision records for a member of staff documented following an incident that they were to have additional training and frequent ongoing supervision. There was no evidence available to demonstrate this had happened. This was not an isolated case.

The provider assessed and managed the risk of infection to ensure people’s safety. Relatives told us, “They [staff] do use gloves when bathing [relative] and doing other tasks. They [staff] are very good as they change them for different jobs” and “The staff wash their hands and put gloves on which they change frequently depending on what they are doing.”

Staff told us they had access to a range of appropriate Personal Protective Equipment [PPE] to keep themselves and others safe. Staff had received appropriate infection, prevention and control training.

The provider did not always make sure that medicines management was safe and met people’s needs, capacities and preferences.

People’s comments relating to the management of medicines were mostly positive. Comments from people and relatives included, “My medication comes in Dossett boxes, and the staff give it to me on time” and “The staff do arrive on time to give [family member] their medication. It is important they get this on time.” Where concerns were raised, this related to the impact of inconsistencies with staff visit times. A relative told us, “My biggest concern is they [Nwando Domiciliary Care] keep altering the times the staff come to my relative and this means they do not always get their medication at the right time. Following our assessment the provider wrote to us advising processes were in place to ensure people received their medicines at the right time. For example, key information about time sensitive medicines for individuals was shared with staff, recorded within people's support plans and included rostering adjustments.

People had a support plan in place detailing the medicines support required and who was responsible for undertaking this task. Medication Administration Records [MAR] viewed showed there were discrepancies. The support plan for 1 person stated staff were responsible for administering their medicines each day. However, daily care notes showed staff were routinely leaving the medicines out for the person to take at a later time. This approach had not been formally assessed and agreed upon by the provider or leadership team. Although the MAR was signed, the member of staff had not witnessed the person taking their medication, including eye drops. This practice was repeated on multiple occasions. Signing records without observing administration creates an inaccurate account of what has occurred, and without proper witnessing, it is unclear whether the medication was taken correctly or safely. Following our assessment the provider wrote to us and confirmed the latter error has since been rectified. We also found omissions in the records made when medicines were administered. We found the MAR was blank giving no indication of whether the medication was administered or not. Where people were prescribed a specific medicine to help prevent the symptoms of indigestion, heartburn and acid reflux, no information was recorded detailing it should be taken at least 30 minutes before a meal or snack. Therefore, we could not be fully assured this was happening. Following our assessment the provider wrote to us about the actions taken to help mitigate the risk of recurrence. For example, the introduction of medication champions and workshops, all staff completing updated training, new MAR form introduced and MARs audited on a weekly basis.

The majority of staff who administered medication had received appropriate training and this was in date. However, not all staff had had their competency assessed to ensure they remained competent to undertake this task safely. A revised staff training plan provided to the Care Quality Commission following our onsite assessment, evidenced 14 members of staff’s medication competency was overdue. Although a medication competency form was in place for a member of staff, the assessment form was not completed as it was blank. Therefore, we could not be assured staff were properly assessed. Following our assessment the provider wrote to us and confirmed despite the above, the provider was 91.35% compliant for medication competency.