Great Park Homecare

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. 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 safe care and treatment and fit and proper persons employed.
 

This service scored 44 (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. They did not always listen to concerns about safety or demonstrate how safety events were reviewed to identify learning and improvement. As a result, lessons were not always learned and embedded to promote safe care.

The provider had systems in place for staff to report incidents and near misses. However, we were unable to see evidence of all incident reports at the time of the assessment. The actions taken to review and analyse the incidents were not robust. The provider did not securely maintain an accurate, complete and contemporaneous record of incidents and accidents. There was also no trend analysis completed following incidents. This meant the provider could not demonstrate lessons had been learned from incidents to reduce the likelihood of similar incidents occurring again. For example, we found 1-person experienced a near miss slip when coming out of their shower. However, the provider did not demonstrate proactive risk management by identifying this incident and sharing learning outcomes with staff. Another person was found to have sores on their skin, and staff were applying creams to treat this without evidence of healthcare professional input. There was no information recorded on the provider’s incident logs about this.

Staff told us they shared learning and communicated well as a team. Staff attended regular meetings to discuss training and people’s needs and participated in supervision meetings.
 

The provider worked with people and healthcare partners to establish and maintain systems of care where safety was monitored and managed. They made sure there was continuity of care, including when people moved between different services. However, there were inaccuracies within some care plans and risk assessments. This increased the risk that people moving between services may not receive safe and consistent care because professionals may not have access to accurate, up-to-date information about their needs and identified risks.
For example, medicine administration records were not accurately maintained for all people being supported with medicines. This meant professionals would not be able to access accurate information about this person’s treatment.

The registered manager told us they completed a home visit when people were referred to the service, this included completing risk assessments and establishing care support needs. The registered manager also told us they would complete the first visit with the assigned care worker to ensure there was continuity for people. They said, “I look at starting visits for 45 minutes, we will then review [the] carer’s feedback, and the service users' feedback a few weeks later and ask if they are happy with this time. I will check the system to see if carers are logging in and out, we can look to increase the visit times if needed. There is a quarterly face to face review with service users. I prefer a face to face as I think it’s good for them to see I am not just a voice on the phone.”
 

The provider did not always work effectively with people or healthcare professionals to understand what being safe meant to each individual or how best to support them to achieve this. They did not consistently focus on improving people’s lives or protecting their rights to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm or neglect. The provider did not always share concerns in a timely or appropriate way.

People using the service were not adequately safeguarded from harm. Systems in place to identify, respond to, and report safeguarding concerns were ineffective. Records showed that safeguarding incidents and concerns had occurred but were not consistently recognised, escalated, or reported.

We also found 1 incident where staff had found 2 tablets on the table and were instructed by the registered manager to administer the tablets to the person, despite not having sufficient information about what the medicines were, if it had already been administered that day and if it was safe to proceed under guidance from a clinician. We raised this concern to the provider. They confirmed there was no recorded follow up or outcome from this incident. This meant people were at potential risk of harm because medicines were not always administered in line with prescribed instructions. The provider could not demonstrate they always followed safe administration of medicine practice.

Staff completed safeguarding training. People and their relatives told us they felt care was safe and did not raise any safeguarding concerns. The provider confirmed there were no ongoing safeguarding incidents at the time of the assessment.
 

The provider did not always assess, monitor and mitigate risks to people's health, safety and welfare. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Guidance for staff on how to manage people’s healthcare needs was not always available. The provider confirmed they had recently transferred to a new system to store care records. At the time of our visit, care plans had not been established on the new system. This meant people were at potential risk of harm due to a lack of available guidance and assessments for staff to follow. The provider confirmed people also did not have paper care plans in their homes. This meant there was a lack of assurance staff had access to clear information to safely and effectively support people.

Risks to people’s wellbeing were not always monitored. The risk assessments in place had identified some risks but did not evidence the involvement of the person or their family. We reviewed 4 care records and found people used emollient creams. However, we found no flammable emollient cream risk assessments had been completed in people’s care plans or risk assessments. This meant the provider had not assessed and mitigated the known fire risks associated with the use of emollient creams. We could not be assured people’s needs had been identified, assessed and managed to ensure they were supported to remain safe. For example, people prescribed anticoagulant medicines did not have detailed falls risk assessments in place to ensure staff were aware of associated risks.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Information about equipment people required to support their care was not always clearly identified within their care plans, and there was no guidance for staff on the safety checks they should undertake prior to using equipment. We found 1 person required a hoist for all transfers. Safety checks for this hoist were not documented and audited. Risks associated with this equipment had not been assessed. This meant equipment-related risks may not be identified or managed consistently, increasing the risk of unsafe care or injury.
 

The provider could not demonstrate staff were always competent and suitably recruited to deliver safe care. They did not always make sure staff received effective support, supervision and development.
There was insufficient assurance that staff were competent to deliver clinical care. Competency checks lacked detail and did not evidence robust assessment of staff skills. Some people using the service required support with skin integrity, diabetes and dementia. Although staff had completed training in these areas, we found no evidence staff had been competency assessed
This meant there was a lack of assurance that staff were supporting people safely and correctly in line with their needs.Recruitment practices were not consistently robust or in line with the provider's policy. We found missing and incomplete application forms, gaps in employment history not explored, and references not always obtained from the most recent employer. We also found healthcare screening questionnaires and photo ID were not always stored in staff records.

Staff completed relevant e-learning training, and the provider had some systems in place to support staff development, including supervision and team meetings. People we spoke with felt staff were trained.
 

The provider did not consistently assess or manage the risk of infection. They did not always identify, monitor or control the risk of infection spreading.
Staff received training in infection prevention and control (IPC). However, we did not see evidence of competency assessments to ensure the safe and effective application of this learning. People's care plans did not always contain sufficient information to support effective infection prevention and control practices. For example, for one person with pressure ulcers, records did not clearly explain the risks of infection. This meant staff may not have sufficient information to monitor for signs of infection or respond appropriately if a person's condition deteriorated.
The provider had not completed audits of IPC practice to ensure any learning was identified and used to drive improvement across the service. People told us staff wore appropriate personal protective equipment (PPE) when providing care. Staff told us they had access to PPE and used this when providing care.
 

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

Although the provider had medicines policies based on national guidance, staff did not always follow these when administering medicines, which increased the risk of errors. For example, records for ‘when required’ (PRN) medicines did not always explain why the medicine was prescribed or provide clear guidance on when and how staff should administer it. This was raised with the provider, and they confirmed there were no protocols in place for PRN medicines. This meant we could not be assured medicines were being offered in line with people’s needs, and in line with the prescriber’s guidance.

We found 1 person’s care plan stated they self-administered their medicines. However, their daily notes showed staff were administering medicines which had been left out by a relative. This meant staff were administering medicines by secondary dispensing and was not in line with the person’s care plan which stated they self-administered their medicines. There was no electronic medicines administration record in place for this person. This meant the provider could not monitor and manage the medicines administration to ensure safe care and treatment. The provider also did not have topical medicines administration records and body maps in place to ensure safe application and monitoring of topical medicines including creams and ointments.
We saw the provider had completed some medicines audits for people’s care records.