Chenai Holistic Home Care Agency 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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of the legal regulations relating to safe care and treatment, safeguarding and staffing.

This service scored 38 (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.

Whilst there were processes in place for recording accidents and incidents. As identified in the safeguarding section the oversight and learning from incidents was not always effective.

People and their relatives told us when they raised safety concerns, these were either not listened to or acted upon effectively. A relative told us they had specifically asked for no spot checks, but this continued to happen which distressed their family member.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They could not demonstrate how they managed or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

We received differing information from the provider about the care being provided, compared to health care partners/commissioners which meant we were not assured people were being supported by staff with the right skills and qualifications to ensure their needs were met safely.

Processes were not effective as some of the information recorded within referral documentation did not match the care the service was delivering.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share or escalate concerns quickly and appropriately.

The provider had not always investigated concerns raised by people and relatives effectively. We identified 2 incidents raised by people or their relatives in January 2025 where the information recorded in the providers records suggested these incidents may require a safeguarding notification. We asked the provider to raise these incidents retrospectively which they did. However, we raised concerns the information recorded in the CQC notification for 2 of the incidents did not reflect the information we had reviewed. The provider told us they had contacted the people and relatives involved in the incidents again and the information was accurate. This did not assure us accidents and incidents were being recorded accurately or investigated robustly at the time information of concern was received by the service.

We received mixed feedback from people and relatives about their safety. A person told us, “I feel if I had a fall no one would know what to do. They rush through tasks and don’t always check if everything is safe before they leave.” A relative said, “Certain staff have been okay, but others have been dreadful. I don’t feel entirely confident leaving them to do things without checking."

However, some people and relatives told us they felt safe. A person told us, “I do not feel in any danger or not safe I just would like to know when they are coming.” A relative said, “I do feel [family member] is safe with them."

Staff had received safeguarding training and were aware of how to escalate safeguarding concerns.

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.

Risk assessments were in place; however, the assessments contained some generic and contradictory information making them confusing and not always specific to the person.

In a care plan we reviewed the mobility care plan and risk assessment indicated the use of a piece of equipment, a note had been added in October 2024 to state this equipment was no longer being used and the care plan and risk assessments had been updated. However, the care plan and risk assessment still included the use of this equipment. There were other instances of conflicting information such as statements confirming a person had bedrails and another statement stating they had no bedrails. This meant we were not assured staff had the most accurate and current guidance in place to refer to and care would be provided for the most up to date assessments.

People and relatives gave us mixed views about how staff responded to risk related to their care and treatment. A relative told us, “[Family member] uses a [specific piece of equipment], and not all the staff know how to use it, even if they have shadowed another member of staff they fumble and can’t use it." Another relative said, “[Family member] was left sitting too long, which caused them discomfort."

Other positive comments included, “They are careful with equipment and ensure it’s used properly."

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 completed an environmental assessment within people’s homes during the initial assessment to check if it was safe for staff to carry out the necessary tasks. However, we were not always assured staff were keeping people’s environments safe. A person told us, “I’ve had to remind them to lock the door when they leave." A relative said, “I have to pick them up on leaving dirty washing on the floor to making sure [family member] is actually kept clean."
 

Other comments were more positive about people's safety within their environment and a person said, "They make sure the environment is safe before they leave."

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs.

The provider had not always ensured staff had the relevant skills to provide people with safe care and treatment. Whilst training was in place, we were not assured the correct competency assessments for specific staff roles were being completed appropriately or that the person completing them was qualified to assess staff competence in some of the areas we reviewed.

People and relatives had mixed views about staffing and whether staff are trained appropriately. A relative told us, “Rubbish training, I am not convinced there is any formal training at all. They are completely unable to deal with [their} catheter." Another relative said, “I have tried so many times to get to the bottom of this poor care and lack of training, but I won’t hold my breath for anything to be done to help.”

Some people and relatives were happy with the competency of staff. A person told us, “Training is good, they work as a team, very happy."

Some staff were positive about the support and training, they received and a staff member told us, “Management regularly checks in with us, offers training opportunities, and appreciates our work. Team meetings and supervisions also help me feel heard and involved.” We also received comments where staff felt the training and support was not effective. A staff member told us, “Carers are not given proper training or supervision before working with complex cases. Concerns raised by staff are often ignored or dismissed, leading to frustration and low morale.”

Policies and procedures were not always followed. Records related to recruitment did not always demonstrate a robust recruitment process. We saw evidence of gaps in references or references being received after staff start dates and gaps in employment history.

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 and relatives gave us mixed views about infection control risks. A person told us, “They don’t always wear gloves or aprons, and infection control is probably not high on their list." A relative said, “They don’t check to make sure [family member] is clean or comfortable before they leave and that is not only uncomfortable for [family member but could lead to infection."

However, other people and relatives did not express any concerns in relation to infection control.

Staff had received training and told us they had enough personal protective equipment (PPE). A staff member said, “We collect PPE from the office and write down what we have collected. As we travel from person to person, we need to ensure we are following correct procedure.” Spot checks were completed which included checks in relation to infection control.

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.

The records we viewed related to medicines indicated people had received their medicines and the medicine administration records were completed in full.

However, the views of people and relatives were mixed in relation to medicines administration. A person told us, “I worry because different carers don’t always know my medication routine." A relative said, “[Family member] had their morning medication twice before now because of their shambolic timing and call management.” Another person told us, “I never have to remind them about my medication, they keep track of everything well." A relative said, “The carer is fully confident to manage his medication, which reassures me."

Staff had received training in safe administration of medicines; however, some competency checks were overdue.