Share the Care Limited Office

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 legal regulation in relation to safe care and treatment, safeguarding and staffing.We found that there were no systems and processes to identify, and act on incidents and safeguarding concerns. Medicines were not managed safely, and infection prevention was not always effective. Staff ran late to care calls, and cut calls short as there was no travel time allocated to them. There was insufficient guidance to inform staff how best to support people with complex conditions.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. Systems to record, investigate and make improvements as a result of incidents were poor and ineffective. Staff documented when incidents occurred within daily notes, however there was no review of these by leaders. We identified multiple incidents including safeguarding concerns that had not been identified by the provider. The provider missed the opportunity to collate incidents and accidents and make improvements for people. People were left at the risk of similar incidents reoccurring.

The provider did not have safe systems and processes to manage or monitor people’s safety. The providers process to assess people before commencing a package of care was not effective. The provider told us that they accepted care packages before knowing people’s needs fully and understanding if they could meet them. When packages were accepted, the assessment of people’s needs was poor and did not include sufficient initial care plans or risk assessments. The provider had accepted a new package of care which commenced in January 2025, at the time of our assessment, staff did not have the relevant training in place to support the person with their rescue medicine. People had not always been supported to be a part of the assessment of their needs.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. Systems to ensure that people were safeguarded from abuse and improper treatment were poor and ineffective. Although staff documented information of concern within daily notes, there was no oversight of this from the leadership team, and therefore opportunities to raise safeguarding had been missed. For example, we identified 2 instances where someone was at risk of financial abuse, but this had not been reported to the local authority safeguarding team. Another person was identified as being at risk due to the progression of their dementia, and despite there being 4 occasions within a month that staff found the person at risk, the provider failed to raise this with the local authority safeguarding team.

The provider did not have a system to record and learn from safeguarding incidents. The provider told us these were reviewed individually, but when we asked to review the investigation for a safeguarding they were unable to produce it. The provider missed opportunities to make improvements to individuals and learn from any patterns and trends.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. The provider did not work well with people to understand and manage risks. The provider told us they approached people’s next of kin, rather than discussing risks with people themselves.

Although most staff we spoke with had a good understanding of people’s needs, care plans and risk assessments to inform staff how best to support people were poor. Some people lived with complex health conditions including wounds, diabetes, epilepsy, stoma care, catheter care, stroke, high blood pressure, mental health conditions and there was no robust guidance to inform staff how to support people safely. Following incidents, or when people’s needs changed care plans had not been reviewed or updated. For example, one person’s care plan stated that they had a wound on their leg. We asked staff and the provider, and they were not certain if the wound had healed or not. Another person’s care plan stated that their skin was intact, however we identified through their daily notes that they had a wound on their leg, and areas of sore skin. This was not reflected in the person’s care plan. People were at risk of staff not having the knowledge to be able to support them safely. One staff member told us they felt care plans were ‘task based’ and not sufficiently detailed.

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. The provider failed to ensure that risk assessments were clear and mitigated risks to people. Risk assessments did not consider all areas of people’s care, for example, when people smoked there was not a robust risk assessment to inform staff how to keep the person safe. Where people needed equipment to help them transfer, the use of this equipment was not detailed within their care plan or risk assessment. For example, one person’s care plan stated they needed to transfer with a hoist. There was no guidance on how to use the hoist safely, or how many staff needed to support the person.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, one person’s care plan stated that they had a mice infestation, but the provider did not note what actions they had taken to inform other authorities, or instructions for staff.

One person’s care notes reflected that staff were greeted by ‘a strong bad smell’ but did not detail what staff did to find the origin of the smell. For example, if this was caused by equipment such as a urine bottle needing cleaning, or if it could be a sign the person had an infection or continence issues. One relative raised concerns regarding the way staff disposed of waste which caused a potential infection risk.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. For example, one person’s care plan stated that they had a mice infestation, but the provider did not note what actions they had taken to inform other authorities, or instructions for staff.

One person’s care notes reflected that staff were greeted by ‘a strong bad smell’ but did not detail what staff did to find the origin of the smell. For example, if this was caused by equipment such as a urine bottle needing cleaning, or if it could be a sign the person had an infection or continence issues. One relative raised concerns regarding the way staff disposed of waste which caused a potential infection risk.

The provider did not make sure that medicines were safe and met people’s needs, capacities and preferences. There was a lack of oversight of medicines administration, and a lack of auditing of medicines. Medicine administration records (MAR) were difficult to review, and did not contain information needed including maximum dosages and what the medicine was for. Creams administration was not always recorded on MAR, and there was no body maps in place to inform staff where to apply the cream.

One person had a rescue medicine to be administered in the event of a seizure. There was no guidance for staff to follow to inform them how and when to administer the medicine safely. The provider told us that some staff had completed online training, however they said that on reflection this was not sufficient training. Other medicines which were administered on an ‘as and when’ basis such as paracetamol did not have any guidance for staff to follow, to inform them of the maximum dosage within 24hours. One MAR chart we reviewed demonstrated that staff had not waited the allocated 4 hours in between dosages.