Helping Hands Lutterworth

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 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. Staff listened to concerns about safety and reported safety events. However, Lessons were not always learnt to continually identify and embed good practice.

Falls, accidents and incidents were recorded, and staff took prompt action following events such as falls, including contacting next of kin and emergency services when required. However, organisational learning from incidents was not always consistently identified or embedded. For example, a medication error highlighted gaps in oversight. The staff member who gave advice about the medicine was not trained to do so, and although training was arranged for the person who administered the medication following the incident, the provider did not address the involvement of the untrained staff member. Incidents involving people expressing themselves verbally or physically were also not reviewed to assess whether staff responses had been appropriate or effective. Incident reviews lacked sufficient detail to identify patterns, themes or emerging risks, limiting the provider’s ability to drive improvement. This meant the service could not always be assured lessons were being learned or acted upon to reduce the likelihood of similar incidents happening again.

Relatives told us they felt reassured by how staff responded when falls occurred. One relative explained when their family member fell, staff contacted them immediately, made the person comfortable and did not attempt to lift them, in line with safe practice.

Staff we spoke with told us there were processes in place for notifying the service about incidents. One staff member said the registered manager and office team talked them through scenarios during team meetings, including what to do in the event of a fall.

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.

The provider needed to strengthen their processes for managing shared care packages, including ensuring clarity of responsibility between agencies and making sure all supplementary documentation was consistently available so staff had the information required to support people safely. People and relatives told us a pre‑assessment was completed before care began, and staff confirmed new people using the service had care plans in place from the outset to guide safe support. The registered manager explained initial assessments were completed face to face, with the option for relatives to join remotely if they were not local. They also told us when a person was admitted to hospital, they liaised with the family and hospital staff to restart care and reviewed any changes to the person’s needs, including mobility, medication and professional involvement.

The provider mostly 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.

People and their relatives told us they felt safe with the care provided. People said they were well supported. One person told us, “Yes, I’m safe. I get on very well with the carers and I know them well.” Relatives also told us they felt assured about the care their family member received. One relative said, “I feel [they are] safe and in good hands with them and I feel secure knowing that they are coming and are professional, they are reliable and there for both of us.”

Staff were able to explain what safeguarding meant and the actions they would take if they had concerns. Staff told us safeguarding involved being alert to signs of neglect, abuse or changes in a person’s wellbeing, such as not eating or drinking properly, and reporting any concerns to the office so these could be recorded and acted upon. Another staff member said safeguarding was about “keeping both people and staff safe” and ensuring care was delivered to the right standards. The registered manager said safeguarding meant keeping people as safe as possible in their own homes and referring concerns to the local safeguarding team when required. They told us safeguarding was discussed in team meetings and supervisions, where staff were asked questions to check their understanding and the actions they would take if they had concerns.

Safeguarding policies and procedures were in place and staff had undertaken safeguarding training. At the time of our inspection, no person had been granted or an application made to the Court of Protection for a Community Deprivation of Liberty Safeguard (DoLS). This occurs when a person lacks capacity to consent to their care and treatment. It protects people who can’t protect themselves.

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.

We found improvements were needed in how risks were documented, monitored and reviewed. One person communicated their needs through their emotions, both verbally and physically, but their care records did not always provide clear guidance on how staff should respond if they became distressed or what factors might contribute to this. When people did become distressed, staff had not always consistently recorded the actions they took, and records were not routinely reviewed to identify possible triggers, patterns or emerging risks. This reduced the provider’s ability to fully understand people’s behaviours and plan effective support. However, some staff were able to describe the strategies they used in practice, which helped to mitigate some of the gaps in written information.

Where people were at risk of falls, risk assessments were in place. For 1 person, this included clear information about the equipment required, how it should be used and the likelihood of the risk occurring.

The registered manager assured us, following our feedback, risk assessments would be reviewed and updated to reflect people’s needs and associated risks. They also confirmed a copy of the person’s positive behaviour support plan had been obtained and added to their care records.

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 risks within people’s homes were identified as part of the initial assessment process. This included key information such as the location of the gas meter and whether a person used a key safe. The provider also had a lone‑working policy and an out‑of‑hours procedure in place, which staff could use to seek support or advice when needed.

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. They did not always work together well to provide safe care that met people’s individual needs.

Most people told us they had no concerns about call times or visit lengths and felt these had improved. However, 1 person said an early morning call was disrupting their sleep. The registered manager told us they would review this. We identified occasions where calls were shorter or later than planned, and staff did not always log out of visits. In 1 instance, there had been occasions where a person who required 2 staff members was supported by only 1; although the family assisted when informed, no risk assessment had been completed to ensure this arrangement was safe. The registered manager said they would put a risk assessment in place. Some people, relatives and staff told us rotas were frequently changed at short notice, which caused inconvenience and made planning difficult. Travel time between visits was usually sufficient, although there were occasions where it had not been appropriately allocated.

Staff had been offered a range of training; however, they had not received training in positive behaviour support, which limited their ability to respond consistently to people who may present with distressed behaviours. The registered manager had booked further training following inspection feedback and said training would be completed by the end of May 2026. Staff received supervision and appraisals, but several staff members told us they felt ‘exhausted’. We found some staff were not consistently supported to work within working time regulations, with limited breaks between the end of one shift and the start of the next. Staff fatigue and insufficient breaks have the potential to compromise the safety and quality of care provided. Safe recruitment processes were in place, including the completion of references and Disclosure and Barring Service (DBS) checks to ensure staff were suitable to work with people using the service.

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.

People and their relatives told us staff wore Personal Protective Equipment (PPE) during visits. One person requested staff wear a facemask when supporting them, and we saw this preference was clearly recorded in their care plan. Staff had completed infection prevention and control (IPC) training, and the provider carried out observed practice checks to ensure staff used PPE correctly and followed IPC procedures when required.

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.

One person had been prescribed an ‘as and when required’ (PRN) laxative; however, there were no clear instructions for staff on when this should be administered. Another person had PRN paracetamol prescribed as “1 or 2 tablets”, but there was no written guidance to help staff decide when 1 tablet was appropriate and when 2 should be given. Staff did not consistently record whether 1 or 2 staff had administered medicines, which created a risk to safety should the person require additional medication or emergency treatment. This meant staff did not have the correct information in place to help them administered medicines effectively to people to help them manage their pain.

One person was prescribed a weekly pain‑relief patch. Records showed staff were not consistently alternating the patch site as required which meant the person was not receiving their medicines in line with best practice guidelines. The rotation of medicine patches is important to ensure the medicine is absorbed effectively and to reduce the risk of skin irritation.

People were also prescribed time‑sensitive medicines that needed to be administered 30–60 minutes before food, but there was no written guidance to support staff with this. Records we reviewed indicated on occasions food and medicines were given at the same time, and nutritional supplements were administered immediately afterwards. This meant medicines may not have been absorbed as intended or may not have had the desired therapeutic effect.

The registered manager assured us they would review these concerns and had already begun making amendments following the feedback shared during the inspection.