Time to Care Specialist Support Services Limited

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 3 legal regulations in relation to safe care and treatment, including medicines, care planning and risk management; staffing and good governance.

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. Staff raised concerns about safety but there was insufficient evidence they were investigated and reported appropriately. Staff told us they did not feel listened too, and their concerns were often dismissed.

Some incidents were documented and some staff debriefs took place following events. However, there was no reflective practice and opportunities to review events and consider how to avoid similar issues in the future had been missed. Organisationally, lessons were not learned to help continually identify and embed good practice.

Staff told us there was no learning shared with them following the reporting of incidents or concerns.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care.

There was no documentation to support the involvement of people, and appropriate others, in developing care plans and risk management plans. Risks had not been robustly reviewed and updated on a regular basis or in response to changes or incidents. Risks identified during an initial assessment process did not always have risk assessments associated with them.

Staff who were new to the people they were supporting did not have a thorough induction to people’s needs nor were they introduced to people. The care planning system was not robust and there was limited information available to staff to ensure safe care and support was provided for people.

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

Most safeguarding concerns were individually documented. Multiple recording systems meant the process was disorganised and senior staff were not aware of the most up to date information. Action taken in response to safeguarding concerns was not always documented, nor was there evidence of learning from concerns to drive improvement and mitigate future risks.

Three allegations of abuse had not been reported to the Commission in line with the provider’s statutory duties. This is being addressed separately. A relative spoke to us about one of their concerns and said they were disappointed with how it had been managed by the nominated individual.

The acting manager told us they were developing a new process.

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, supportive and enabled them to do the things that mattered to them.

Some people said staff spoke with them about their day-to-day needs. The views of people and their relatives were not recorded in care records. Risk assessments and care plans did not highlight the actions staff should take to mitigate risks. One person had a choking risk assessment but there was no information in the care plan. Staff told us the person had not been assessed by a healthcare professional such as speech and language therapy in relation to how the risk should be managed. Another person had a risk assessment which listed refusal of medicines as a potential risk. The risk assessment document stated for staff actions that they should refer to the person’s care plan for actions. The care plan contained no information as to how staff were to manage refusal of medicines and when they were to consult with other professionals.

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

Some people lived independently in a supported living environment in a small residential complex. Staff had developed personal emergency evacuation plans (PEEPs) for each individual in the building. When asked about these plans, staff were initially not able to find them, as they were not filed under people’s care documentation. When they were located elsewhere on the system we noted they were dated 18 January 2025. The documents stated they should be monitored and reviewed every six months, with a full formal review every 12 months. These reviews had not taken place.

A fire evacuation information document was in place in relation to the residential flats where people lived. This was dated 27 March 2023, with no documented review to ensure it was still accurate and met people’s and fire safety needs.

There were enough staff, but the provider did not make sure they were appropriately skilled and experienced. They did not 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.

A range of training was provided, but completion levels for some training was low. Some people had complex needs and staff told us they had requested specialised training to ensure they understood people’s health conditions, so they could better meet their needs. This was recorded within some staff members’ supervisions. However, this had not been provided. The acting manager said, “I have asked staff what training they wanted but no one came forward and said anything.” This had not been followed up with staff. People told us staff did not always know how to best support them and did not have knowledge of their care needs.

One person told us, “I’m not comfortable with some of the agency staff in the morning. When showering I don’t feel very comfortable.”

There was limited evidence agency staff received appropriate induction before starting work. The acting manager explained an induction file was available. This included examples of medicine administration records, daily appraisals and incident reports and a confirmation sheet for staff to sign. A document detailing when incident forms were needed was also in place. The acting manager told us, “The person responsible for agency staff induction is the senior person on duty.” A staff member told us, “It’s management’s responsibility to induct staff.” The induction signature sheet was not counter signed by a permanent staff member to indicate they had gone through the induction process with newer staff and that they were competent to support people.

There was no system in place to ensure people received their full commissioned hours of support. Senior staff confirmed this was case. We could not be sure people were receiving their full contracted hours and the support they needed to meet their assessed needs. This information has been shared with the local authority commissioning team.

Supervisions had taken place; they were irregular and staff felt they were not supportive or productive.

Recruitment procedures were inconsistent. For example, full employment histories were not always present and/or gaps in employment were not explained. Not all references correlated with previous employment history. Right-to-work checks and DBS checks were completed prior to staff starting work. A new recruitment checklist had been designed to monitor and manage pre-employment screening and on-boarding processes however this had not been fully embedded.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Where people had consented to us visiting them at home, we saw their homes were clean and tidy. People commented that staff were very good at doing the basics such as helping them keep their home tidy and supporting with the washing. Staff had completed training in infection prevention and control.

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, including when changes happened.

The storage of medicines was not safe. People living in the housing complex had consented to staff storing and managing their medicines for them. These medicines were stored in a locked communal cupboard in a haphazard manner. Some medicines were stored in open drawers or in baskets. Three bottles of morphine sulphate were available but they had been signed in and accounted for.

Some medicine administration records were handwritten. However, these records were not counter signed in line with good practice guidelines to show they had been checked and the correct information recorded.

Protocols for the administration of ‘as and when required’ medicines were in place, but they did not contain sufficient information to support safe administration. Medicine records did not always include the time people had been administered ‘as required’ medicines. One person had received paracetamol within the four-hour administration gap and there was no indication medical advice had been sought, or action taken to minimise the risk of reoccurrence.

Some medicines and topical cream remained in place, even though staff told us they had been discontinued.

Records were disorganised with frequent crossings out, meaning we could not be assured medicines were administered safely and in line with prescriptions. The acting manager told us, “I have re-done ‘as and when required’ medicines protocols since the feedback.”