Regional Care Peterborough

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 remained 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 continued breach of legal regulation in relation to people’s safe care and treatment, including the ways people’s medicines were managed.

This service scored 59 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although the provider had a system in place to record and learn from accidents and incidents, this was not always used consistently or effectively. People gave mixed feedback about how well incidents were recognised, recorded, and used for learning. For example, one person described an incident that had occurred, which had not been recorded as an accident. The registered manager also told us they were unaware that staff had been present at the time. This indicated that opportunities to learn from incidents may not always have been fully embedded, resulting in only limited assurance that risks were consistently identified and managed.

However, there was also more positive feedback. Some people told us the service responded appropriately when they contacted the office. Staff said they discussed incidents and lessons learned during regular meetings and supervision sessions. We reviewed team meeting notes which showed that concerns and incidents were discussed, alongside clear guidance from leaders on how to reduce the likelihood of similar events happening again.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s needs were assessed by senior staff before their package of care commenced, and risk assessments and care plans were put in place at the start of their care. However, there was no system in place to notify GPs when the agency began providing care. This meant the service could not be assured that important information, such as changes in medication, was always shared in a timely way. When people’s needs changed, staff told us they reported these concerns to relevant healthcare professionals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had been trained in protecting people from the risks of abuse and understood how to report any concerns to the care coordinator or registered manager. Staff told us they believed the registered manager would act on concerns, and ensure people were protected. The registered manager had identified when incidents were of a safeguarding nature in the past, however there had not been any in the last year.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care records reviewed either did not fully assess or clearly plan for how to mitigate some people’s risks. There were areas where key risk assessments or detailed guidance in people’s care plans were missing or incomplete, including for skin integrity risks and risks associated with people’s health conditions. Some risk assessments contained generic information to inform staff about risks related to people’s health. These had not been personalised so that staff knew what action to take to reduce risks to people where needed. For example, one person’s diabetes risk assessment contained generic information about diabetic care but did not contain clear information about how the person should be monitored and supported and when and who to contact when any issues arose. The skin integrity risk assessment included in the care plan did not include all relevant risk factors when assessing the level of risk to the person. For example, existing medical conditions were not taken into consideration. Not all risk assessments had been regularly reviewed. Following our feedback the registered manager made improvements to the records during the assessment.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental risk assessments had been completed to identify potential hazards in people’s homes and to help ensure the environment remained safe. The relative of one person who uses the service told us, “Very safe, they move him safely, they know his capabilities.” The office was used by various staff and included checks such as fire safety measures and general housekeeping to ensure the premises remained safe and well-maintained.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff had not always completed training to meet people’s specific needs such as epilepsy and end of life care. Systems were in place to ensure that staff were recruited safely with appropriate pre-employment checks completed, including references and Disclosure and Barring Service checks. New staff received an induction, supervision and mandatory training.

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.

Staff followed appropriate infection prevention and control (IPC) measures. People told us staff used personal protective equipment correctly and maintained hygiene standards. A person said, “Yes, I`m safe, they wear gloves and an apron and put them in the bin or take them with them.” The relative of one person who uses the service told us, “They are in a routine now and wear gloves, aprons and when necessary, they put them in bags and then in the bin when finished-they also wash their hands as well.”

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

We were not assured that medicines were administered safely, as medicines records were unavailable during the inspection. We were unable to see evidence that people received medicines safely and appropriately, due to the lack of access to records during this inspection. Although data was provided following our office visit, detailing individual administrations, we could not see if this was in accordance with prescriber’s instructions or if relevant medicine cautions were being followed consistently.

Medication risk assessments did not always meet people’s needs. For example, risk assessments indicated that staff should be present to check when the person administered their self-injectable medicine to ensure the correct dose had been administered. However, there was no information about how staff would record this and what action they would take if there were any issues found when monitoring blood levels that were required to support the safe administration of this medicine. Risk assessments did not always contain relevant information, often referring to the wrong person for which the risk assessment had been written. There were also instances when annual reviews of risk assessments had not been completed regularly.

Staff competency records we saw, showed that staff have completed medicines administration training. However, staff were not always assessed against all the criteria included in the competency assessment. For example, one member of staff had been assessed applying creams but had not been observed administering tablets. This did not provide assurance that they would handle certain forms of medicines safely. We were informed by the provider that they would use medicines e-learning to support staff in this instance. Staff also failed to provide evidence of training in the management of chronic conditions, such as epilepsy, despite assurances on-site that this had been done.

We were told by the registered manager that there were no written audit criteria for medication audits. Following the inspection the registered manager provided medication audits. The audit tools and measures sent after the inspection did not match what we were told during the visit, but we have since been provided with assurance by the provider that new medicines audit processes will be put in place to support the service being provided.