Caremark Tunbridge Wells, Tonbridge and Malling

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.

This service scored 53 (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 learning culture. Systems for identifying, investigating and learning from incidents and concerns were in place; however, learning was not consistently embedded into practice to improve outcomes for people.

The provider had developed systems to collect feedback, including complaints, incidents, phone monitoring and reassessment visits, which informed improvement plans. For example, care packages had been adjusted based on feedback about call times and individual routines.

Staff were aware of incident reporting processes and described actions taken following events, including refresher training and communication through internal systems.

However, people’s experiences demonstrated that learning was not consistently embedded. Relatives reported concerns about, inconsistent staff knowledge and missed or delayed calls, which indicated recurring issues rather than sustained improvement. One person said, “Its up and down really. Sometimes they are on time, I suppose there has been an improvement recently though”

This showed that although systems existed to identify risk, the provider did not always ensure that lessons learned resulted in consistent changes to practice across the service.

The provider did not always ensure systems, pathways and transitions were safe or effectively managed, resulting in inconsistent care delivery and increased risk to people.

People and relatives reported variability in care delivery, including delayed visits, missed calls and inconsistent call times, which impacted people’s ability to receive care at the time they needed it.

There were also examples where systems did not support continuity of care. For example, people reported receiving care from multiple different staff members, which increased risk where needs were complex or required specific knowledge and consistency. One person told us, “The cover is vary variable, I have different carers sometimes which isn’t ideal.”

Although electronic monitoring systems and communication tools were in place to oversee care delivery and manage scheduling, these were not always effective in preventing delays or ensuring safe transitions between carers.

The provider had taken steps to improve systems, including reviewing rotas and travel times and introducing improvement plans; however, these actions had not yet resulted in consistently safe care delivery

The provider did not always ensure safeguarding systems were consistently effective. While staff understood safeguarding and escalation procedures, organisational systems for recognising, recording and reporting concerns were not always robust.

There were inconsistencies in organisational oversight of safeguarding. The provider did not always demonstrate that safeguarding concerns were promptly recorded or reported to appropriate bodies, and processes required strengthening to ensure compliance and transparency.

Staff demonstrated an understanding of safeguarding and were able to describe processes for identifying and reporting concerns, including escalation to the office and external agencies where required. There were examples of staff responding appropriately to risk, including escalating concerns about deterioration or potential medical emergencies. One staff member told us, “I take safeguarding very seriously. Abuse is unacceptable even it is coming from a loved one.”

In addition, concerns raised by relatives, including issues relating to medicines and potential misuse, indicated that people were not always protected from risk or harm. We spoke to the provider about this and although they were not involved with a person’s medicine, they agreed that this should have been raised with the appropriate authorities.

This showed that safeguarding systems were not always consistently embedded or effective at ensuring people were fully protected from abuse or avoidable harm.

Where people were deprived of their liberty, appropriate authorisations were in place. Any restrictions were applied lawfully, in line with the Mental Capacity Act 2005, and were proportionate, in the person’s best interests, and the least restrictive option.

The provider did not always involve people effectively in managing risks relating to their care, and risk management processes were not consistently person-centred.

People and relatives reported limited involvement in care planning and risk management. Some said they had not seen care plans or were unclear about how risks were being managed.

There was evidence that feedback from people was used to make adjustments to care delivery, such as changing call times to better reflect individual routines.

Therewere concerns about inaccuracies in care records and communication, including situations where carers’ notes did not reflect people’s actual experiences or needs. For example, one person’s notes stated that their loved one had been calm, but in fact that had been quite agitated and uncomfortable. This meant care was not consistently informed by their needs or experiences, increasing the risk of unsafe or inappropriate support. Inaccurate records further heightened this risk by leading to care being delivered based on incomplete or incorrect information.

his indicated that the provider did not consistently ensure people were actively involved in identifying and managing risks or that their experiences were reflected accurately in care planning.

The provider identified and managed environmental risks to support safe care delivery.

The provider undertook environmental risk assessments and took action where risks were identified, including delaying the start of care packages until environments were made safe. For example, where cleaning or safety concerns were identified.

Staff were also expected to escalate environmental risks when identified in people’s homes, and systems were in place to support this.

Environmental risks were well managed; oversight was dependent on individual staff recognition and escalation.For example, staff phoned the office if there were concerns with the condition of some people’s properties.

The provider did not always ensure there were sufficient suitably skilled and consistent staff to meet people’s needs safely. While staffing levels were generally maintained, inconsistencies in staff allocation, experience and continuity affected the quality and reliability of care.

People and relatives described significant variability in staff consistency and competence. Feedback highlighted frequent changes in carers, a lack of familiarity with people’s needs and occasions where staff did not have the required skills to deliver care safely. For example, one person told us, “They never knew who was coming” and others reported that “Some are better trained than others” and that they had to explain how care should be delivered.

There were also concerns that inexperienced or unfamiliar staff were sent to support people with complex needs, which increased the risk of unsafe or ineffective care. Some people reported that carers did not always understand how to provide appropriate support and, in some cases, did not complete required care tasks.

The provider maintained recruitment activity and described ongoing efforts to address staffing pressures, including onboarding new staff and adjusting rotas. Staff reported they had access to training, supervision and management support and generally felt listened to.

These inconsistencies meant people did not always receive safe, reliable or person-centred care. A lack of continuity increased the risk of errors, reduced confidence in the service and required people and relatives told us they felt the need to take a more active role in overseeing care to ensure needs were met. There was also a variability in skill, experience and allocation meant staffing arrangements were not consistently effective in supporting safe care delivery.

The provider did not always ensure consistent infection prevention and control practices.

Policies were in place and staff had access to PPE (Personal Protective Equipment); however, people and relatives reported inconsistent use of PPE, including occasions where staff did not wear gloves or aprons appropriately. One person said, “It’s pot luck with which carers wear gloves. I have raised it with the office and it has improved but not perfect.”

We raised this with the provider and we were shown sufficient supplies of PPE at the office. We were also shown evidence that use of PPE was spoken about at team meetings.

These inconsistencies increased the risk of infection transmission and indicated that IPC practice was not consistently embedded.

The provider had systems in place to support medicines management; however, these were not always consistently effective.
 

Staff received medicines training and were expected to follow protocols for administration and documentation.

However, people and relatives reported concerns about medicines timing, administration and recording, including inconsistencies in adherence to prescribed schedules.

There were also examples where medicines-related issues required escalation or correction, indicating variability in staff competence and system effectiveness. For example, there was ineffective communication with people’s relatives around medicine administration and storage. This meant that there was a potential risk of overdosing of medicines. We raised this with the provider and assurances were given that processes would be tightened and streamlined.