Archived: Willow Home Care Ltd

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 requires improvement. 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 people’s safe care and treatment.

This service scored 28 (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. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Where accident and incidents happened, there was no reporting process embedded and records were not always maintained. For example, we identified a person had a fall within the last 12 months, this was not recorded on accident and incident forms and only identified through speaking to people, who informed us of their falls. Management did not complete an analysis of accidents and incidents to identify themes and learning for the future. Care plans and risk assessments were not consistently reviewed to ensure people received consistent care from staff. Where care needs had changed, these were not identified within care plans and risk assessments. Staff we spoke with were not aware of the formal reporting and recording of accidents and incidents.

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, including when people moved between different services. After our assessment, the provider submitted evidence of the involvement of other health care professionals involved in people's care. There were no effective processes in place for staff to follow to ensure the needs of people who had additional health care needs were met. Care plans lacked detail and did not provide staff with clear guidance on how to appropriately provide personalised care. Since the assessment the provider has informed us they have taken action to update care plans. This will be assessed at the next assessment. People told us they had not received a copy of their care plans. People told us they had not been involved in the process of completing their care plans. We found care plans had discrepancies of information in them. This was not identified by the provider through any monitoring process. No process was in place for reporting and recording accidents and incidents. Staff did not complete accident or incident forms when people had a fall. We found 4 incidents had not been reported and staff had not followed the provider’s policy.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. We identified safeguarding incidents where people had experienced a fall, and staff had not reported or recorded the falls or followed the provider’s policy and procedure. Inspectors were made aware of the falls by speaking with people and looking at daily notes. Staff were sent to provide care to people without having the appropriate induction or training. 1 serious incident was identified where a staff member had gone to provide care to a person who was known to have a diagnosis of dementia and could, at times, experience periods of distress. This resulted in the staff member being physically hurt by the person. We raised the incident with the manager, who was not aware of the incident and had therefore failed to investigate or put control measures in place to mitigate this happening again.

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 people to do the things that mattered to them. Risks to people’s health and welfare had been identified but had not been appropriately assessed. The risk assessments did not contain detailed guidance for staff to manage and mitigate risk, and some guidance was generic and not person centred for many of the risks identified. For example, 1 person had a diagnosis of Arthralgia (this means pain in one or more joint). No guidance or information on how to help relieve pain was documented in their care plan. People’s care plans did not always contain accurate information about their support and care needs and guidance was not personalised. For example, people’s personal characteristics including their age was incorrect in their care plans. 1 person’s age was recorded, however, when checking their date of birth, the age recorded was incorrect. Where people had a diagnosis of learning disabilities there was not enough guidance in their care plan to effectively provide support to meet their needs. Where people were at high risk of constipation this was not mitigated in any risk assessment. Appropriate records such as charts were not in place to monitor the person’s health needs. We raised this with the manager who told us the person received care from another provider as well as Willow Home Care Ltd, and the other provider were mainly responsible. However, this evidenced no communication process was in place to ensure effective monitoring was in place. This placed the person at high risk of further negative health implications. This put people at risk of unsafe care and increased harm.

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 had completed environmental risk assessments and potential risks had been identified. However, the guidance to mitigate the risks and keep people safe was not always present in people’s care plans and risk assessments. We could not be assured equipment used by staff to support people including hoists had been checked to make sure the hoist was in working order and meeting Lifting Operations and Lifting Equipment Regulations (LOLER) standards and checks.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. They did not always make sure staff received effective training, support, supervision and development. Recruitment checks were not carried out safely. Where staff were on a sponsored visa, this was not checked, and copies were not taken to evidence their right to work in the UK. For example, 1 staff member was on sponsorship with another provider. Willow Home Care Ltd failed to complete checks or obtain copies of their right to work. We could not be assured all staff had the correct documentation. There were gaps in employment histories which had not been explored to check the reason for the gap. We could not be assured the competency documentation completed was accurate or that spot checks had taken place. For example, 1 staff member had failed their competency assessment. It was recorded they had failed, however no further action was recorded to show the action taken. The records were inconsistent. The manager told us the induction was a 3 day classroom exercise. There was no evidence new staff had shadowed more experienced staff to learn how people liked to be supported, or what training each staff member had completed. Since the assessment, the provider has evidenced 1 staff members shadow documentation. There was no evidence staff training was monitored to check staff were completing required courses. These courses included essential training such as administering medication. The manager told us they provided all the essential training. However, records did not identify the specific training courses completed. We could not be assured staff were safe to support people. This placed people at increased risk of harm.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. People’s care plans did not contain information and guidance for staff to reduce the risk of infection. This placed people at risk of not receiving support which promoted infection prevention and control. Staff understood their responsibilities to wear personal protective equipment (PPE) when supporting people. Staff told us they did not always have access to PPE as this was stored at the main office which was of distance to them. One person told us, ‘Staff do not always wear gloves and aprons.’

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People’s medicines were managed poorly. Medicine records such as medication administration records (MAR) were on an electronic system. The system did not provide assurance medicines were being administered safely and as prescribed. For example, 1 person was prescribed patches for pain relief. The prescription stated to prevent irritation or skin breakdown this needed to be alternated weekly between the person’s left and right arms. No body maps were in place. We asked the manager how they monitored this action was completed, they told us this was recorded in the daily notes. We checked the daily notes for 4 weeks and there was no evidence the changing of the patch was recorded. The provider did not follow the NICE guidance regarding record keeping and body maps. Where people had prescribed creams, we could not consistently identify where these had been applied due to poor record keeping. As required (PRN) medicines had no protocols. This meant staff had no guidance on how to identify when a person needed the medicine, the desired outcome and the escalation process to complete if not seeing the outcome expected. Care plans did not record people’s up to date medicines and some care plans had the medicine section blank. This meant staff would not be aware of what medicines the person was taking if they needed to provide this information in a medical emergency. We could not be assured staff were trained and competent to administer medicines, placing people at increased risk of harm.