Gogomadu Cares

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 person 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. Lessons were not always learnt to continually identify and embed good practice.

The provider’s approach to learning from accidents and incidents was not consistently effective. Although staff reported that incidents were escalated to the care manager in a timely manner, incident records were not always shared promptly, which limited assurances that concerns were reported to external stakeholders in a timely manner.

For example, For example, we found 2 incident records that had not been passed to the leadership team for review 2 weeks after the event. This meant a statutory notification had not been submitted to the Care Quality Commission for a notifiable incident.

We found the provider had implemented a monthly review process for accidents and incidents. However, this did not consistently identify patterns, trends, or opportunities for learning at individual or service-wide level. As a result, there was limited evidence to demonstrate how incidents were analysed to drive improvement or reduce the risk of recurrence.

We found learning from incidents was not effectively cascaded to staff. This meant we could not be assured that lessons learnt were embedded into practice or used to improve outcomes for people.

These issues indicated that the provider’s systems and processes for learning were not robust.

The provider acknowledged the shortfalls during the assessment and told us they were taking steps to introduce a new incident reporting system to strengthen oversight of accidents and incidents.

The provider’s processes to support safe systems, pathways and transitions were not always effective. They did not always make sure there was continuity of care, including when people moved between different services.

A relative told us their loved ones transition from hospital was, “Good.” The relative also told us, “The manager communicated with me by email and phone, taking an interest. They are trying to manage [relatives] complex situation and I do feel [relative] is safe.”

However, we found systems to support safe transitions were not consistently effective. Health and care passports were in place but not always accurate and required strengthening. For example, one passport did not reflect the person’s current communication needs, including use of an electronic communication board.

The provider had agreed to undertake a delegated healthcare task for an individual requiring support with a specialist clinical intervention. We found that the provider could not evidence robust governance arrangements to support the safe delivery of this task, in line with recognised best practice principles for this care pathway.

These concerns meant we were not fully assured that the provider’s processes to support pathways and transitions were safe.

People told us they felt safe, and staff demonstrated good knowledge of safeguarding, including how to recognise and report concerns.

There was evidence of safeguarding referrals being made appropriately, and the provider had received positive feedback from the local authority regarding their response to reported incidents.

However, we found the provider’s safeguarding policy did not provide sufficient or up-to-date guidance. For example, it lacked reference to local authority processes, including the local safeguarding board decision-making framework, and did not fully reflect nationally recognised types of abuse, included some outdated terminology, and lacked an effective process for tracking outcomes and learning.

There was no effective system to analyse safeguarding themes or trends, and limited assurance to show how learning was used to drive improvement across the organisation. This meant that while safeguarding concerns were being reported, governance arrangements required strengthening to ensure safeguarding processes were robust and fully aligned with current guidance.

The provider did not always work with people to understand and manage risks.

The provider’s systems to assess and manage risks were not consistently effective.

We were not assured that all risk mitigation plans were in place for known risks, or that existing plans provided adequate guidance for staff to mitigate identified risks. For example, risk assessments, including those relating to mobility, PEG, choking and medicines, lacked sufficient detail to support safe practice.

Falls risk assessments did not clearly describe the risks identified or provide meaningful actions, and information was not consistently triangulated across other records relating to falls or mobility.

This meant we could not be assured that risks were being effectively assessed, communicated, and managed.

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.

The provider carried out a range of statutory compliance checks, including gas safety checks. However, we found systems to assess and manage environmental risks were not consistently effective.

The provider carried out an environmental risk assessment as part of people’s transition to the service. However, we found some were completed as a tick-box exercise and did not provide sufficient detail to support safe practice. For example, records relating to utilities such as gas did not record key information, including location of the emergency shut off.

We found that personal emergency evacuation plans (PEEPs) were not in place for a person who required support using the stairs. This limited assurance that staff had adequate guidance to support safe evacuation in an emergency.

The provider’s systems to ensure safe and effective staffing were not robust.

While people, relatives and staff told us there were enough staff, we identified significant concerns in relation to the governance of recruitment and training.

Safe recruitment practices were not in line with regulatory requirements, or the provider’s own recruitment policies. For example, all the staff files we viewed during the assessment were found to be non-compliant. We identified concerns in relation to missing references, employment histories, and Disclosure and Barring Service (DBS) checks.

Staff feedback indicated training and induction was not always effective or sufficiently detailed. For example, staff told us induction and shadowing processes lacked structure and clear expectations. We were also not assured that mandatory learning disability and autism training met the Oliver McGowan standard.

The concerns we identified meant the provider could not demonstrate that safer recruitment processes had been followed and exposed people to the risk of receiving care from staff who had not been safely recruited.

We asked the provider to take immediate action to address our findings in relation to safe and effective staffing.

The provider’s systems and processes did not always provide assurances they would adequately assess or manage the risk of infection.

The provider had sufficient stocks of personal protective equipment (PPE) available for staff, which supported safe practice.

The standard of cleanliness in a supported living home we visited required improvement. For example, we noted on two separate occasions the stairs were not clean. We shared this feedback with the care manager who assured us this would be addressed.

The provider had an infection control policy. However, although this had been reviewed in the last twelve months, we were not assured the review had been effective or sufficiently robust.

For example, it referred to another organisation by name, which indicated the document had not been appropriately reviewed or amended to reflect the provider’s own service. In addition, the policy referenced a Government agency that was abolished in 2013.

This meant we were not assured that staff were provided with up-to-date and accurate guidance to support safe infection, prevention and control practices.
 

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

The provider had a medicines policy. However, although this had been reviewed in the last twelve months, we were not assured the review had been effective or sufficiently robust.

For example, there was no reference to the safe storage of medicines requiring temperature control below 25°C, no guidance regarding the required frequency of staff competency assessments, and no guidance in relation to enteral feeding or medicines administration through a PEG (Percutaneous Endoscopic Gastrostomy).

We found that medicines competencies completed by the provider did not include direct observation of staff administering medicines. The training manager confirmed that competencies were completed using feedback from Team Leaders rather than direct assessment of practice by the person signing off the competency assessment. This meant we were not assured staff were competent to administer medicines safely.

We found ‘as required’ (PRN) medicines protocols were not all adequate. We also found there was no PRN protocol for one person’s PRN medicine and staff were unaware of the reason the person required this medicine. This meant there was an increased risk the person would not receive prescribed medicines, if required.