My Carer

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.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 culture of safety or effective systems to identify, monitor and embed learning from accidents, incidents and concerns.

The registered manager told us they would always respond to accidents, incidents and concerns when these were brought to their attention. Staff and people using the service described positive relationships and told us there was regular verbal communication about concerns and actions taken. However, these discussions were not always documented or formally reviewed.

The provider did not have effective systems to oversee accidents, incidents, concerns or learning across the service. There was limited evidence of trends and patterns being analysed, or of information being used to identify risks, improve the quality of care or achieve better outcomes for people. Records did not consistently demonstrate that lessons learned from incidents and concerns had been formally captured, shared with staff or used to drive improvements in practice.
As a result, the provider could not demonstrate how learning from events was embedded across the service. This reduced assurance that opportunities to improve care, prevent recurrence and promote positive outcomes for people were consistently identified, acted upon and monitored.
Despite this, care records evidenced individual incidents and accidents when they occurred, and staff were able to clearly describe the actions they would take in response. One staff member told us, "[If there are] any accidents, we call the manager, record the incident, let the family know and if it's an emergency, I will call the ambulance."

Whilst staff understood their responsibilities for reporting concerns and responding to incidents, governance systems were not sufficiently robust to demonstrate how learning was reviewed, shared and used to support continuous improvement across the service.
 

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.

Professionals spoke positively about the service's partnership working, describing effective collaboration, flexibility in responding to changing needs, and continuity of care that helped build trust and stability. Records showed referrals had been made to GPs and other healthcare services when required, and staff worked with external professionals to implement recommendations and ensure appropriate support. Relatives confirmed they were kept informed of changes and concerns.

However, systems to support the safe transfer of information were not always effective. Records were not consistently updated following changes in people's needs, hospital appointments or professional input. Information contained within care records did not always reflect current risks, support needs or guidance from healthcare professionals. This increased the risk of staff and partner agencies working from inaccurate or incomplete information.

The provider relied heavily on the registered manager's knowledge of people using the service to maintain continuity of care. While the registered manager demonstrated a detailed understanding of people's needs, this did not provide assurance that accurate and up-to-date information was readily accessible to all staff and external professionals when required.

In addition, the provider had not implemented hospital passports for people with learning disabilities. This meant important information about people's health needs, communication requirements, preferences and reasonable adjustments may not be consistently available or shared when people attended hospital appointments or transferred between services, placing them at risk of receiving care that did not fully meet their needs.

Following feedback, the registered manager acknowledged these concerns and took immediate action to review and update care documentation. However, improvements were required to ensure information-sharing systems consistently supported safe transitions and continuity of care.

The registered manager acknowledged these concerns and took immediate action to review and update care documentation, demonstrating a commitment to improving record-keeping, continuity of care and effective information sharing.

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 concerns quickly and appropriately.

Systems were in place to help protect people from the risk of abuse. The provider had safeguarding and whistleblowing policies and procedures, and staff had completed safeguarding training. Staff demonstrated an understanding of different types of abuse, the signs that may indicate a person was at risk, and the actions they should take to report concerns and keep people safe.

However, safeguarding governance and oversight were not consistently effective. Records showed safeguarding concerns were not always subject to robust review, and there was limited evidence that incidents and concerns were routinely analysed to identify patterns, trends or recurring risks. As a result, opportunities to learn from safeguarding events and implement preventative measures were not always clearly demonstrated.

Management oversight of safeguarding activity was insufficient to provide assurance that all concerns were effectively monitored and used to drive improvements in practice. The provider was unable to consistently demonstrate how learning from safeguarding incidents informed service development or reduced the risk of future harm. This meant systems for safeguarding people were not always operated effectively, and the provider could not

People told us they felt safe receiving support from the service. People knew who to contact if they had concerns about their safety and were confident action would be taken. One person told us, "I could ring the care office or the police or anyone like that," whilst another said, "I could phone the office and tell them."

Staff understood their responsibilities to protect people from abuse and were able to describe the provider's safeguarding processes, including how concerns would be reported and escalated to managers and external agencies where required.

The provider did not work effectively with people to understand and manage risks. Staff did not consistently have access to accurate and up-to-date information about people's identified risks, which meant they could not always be assured they had the guidance needed to support people safely.

Systems for identifying, assessing and managing risks to people's health, safety and welfare were not effective. Risk assessments were incomplete, lacked sufficient detail and were not consistently reviewed or updated when people's needs changed. Records relating to diabetes and epilepsy did not contain important information about signs, symptoms, potential complications or the action staff should take to respond safely. This meant staff could not rely on care records to provide clear and accurate guidance for managing identified risks.

Significant concerns were identified in relation to the management of people with complex health needs. Care plans and risk assessments did not provide staff with the information required to safely undertake specialist care tasks, including catheter care, stoma care and percutaneous endoscopic gastrostomy (PEG) care. There was a lack of guidance to mitigate associated risks, including infection, equipment-related complications and deterioration in people's health.

For one person living with dysphagia and receiving nutrition via a PEG, risk management arrangements were inadequate. Records did not contain sufficient guidance on supporting the person's nutritional needs in line with professional recommendations. Guidance relating to choking risks was limited and did not clearly set out the action staff should take in an emergency, including when and how concerns should be escalated. This placed the person at risk of receiving unsafe care and delayed responses in the event of a medical emergency.

We also found significant failings in the management of severe allergies and anaphylaxis. For a person prescribed emergency adrenaline medication due to life-threatening allergies, there was no personalised risk assessment or emergency response plan in place. Records did not describe how the person may present during an allergic reaction, where emergency medication was stored, how it should be administered, or the action staff should take if the person's condition deteriorated. There was no information about previous allergic reactions to support staff in recognising early warning signs. Training records did not demonstrate staff had received training in the safe administration of emergency adrenaline medication. These failings meant the provider could not demonstrate staff were equipped to respond safely and effectively to a foreseeable medical emergency, exposing people to a significant risk of harm.

Records also contained limited evidence that people, or those important to them, had been involved in decisions about managing risks. Documentation did not consistently demonstrate that people's views, preferences and desired outcomes had been considered when planning care. This meant the provider could not be assured that risk management approaches promoted people's rights, choice and independence.

Although staff were able to describe people's needs and relatives generally spoke positively about the support provided, the provider's systems and processes for assessing and managing risk were not robust. The widespread nature of the concerns identified meant the provider could not demonstrate risks were consistently recognised, assessed and managed safely. People were exposed to the risk of avoidable harm because care records, risk management arrangements and staff guidance were insufficient to support safe care.

We discussed these concerns with the registered manager, who acknowledged the issues identified and told us action would be taken to review and update risk assessments and care planning documentation. However, the concerns identified demonstrated serious and systemic failings in the provider's approach to risk management.

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

Processes were in place to ensure risks within the environment were assessed and monitored. Assessments of people’s home environment were carried out covering areas such as home security, gas and electrical appliances and ensure people were supported in a safe, clean and clutter free environment.

Staff described recording information about people's homes, equipment and preferred ways of working to help ensure consistency and safety. A staff member told us, "I recorded on the notes of our app where equipment is kept and how[person] liked to do it." Staff also told us managers shared important information before first visits to help them understand any risks and support needs, which contributed to people receiving safe and personalised care.

The provider ensured there were enough suitably qualified, skilled and experienced staff in place. Staff received appropriate support, supervision and opportunities for professional development.

We saw evidence that Disclosure and Barring Service (DBS) checks had been completed and that right‑to‑work checks were in place.

Records showed staff had completed mandatory training in areas such as safeguarding, infection control, moving and handling and health and safety. Staff received training delivered both online and face to face.

Staff received regular supervision and appraisal to support and review their performance and development. The provider had a designated, appropriately trained member of staff responsible for overseeing staff training, competency assessments and spot checks. Staff competency was assessed through observations of practice, where staff were observed carrying out their duties to ensure care was delivered safely and in line with people's needs. Where areas for improvement were identified, action was taken to provide additional support, guidance or training.

We reviewed 4 staff recruitment files. Recruitment processes were generally effective in helping to ensure suitable staff were employed. Appropriate checks had been completed prior to staff commencing work. However, records did not always clearly demonstrate how interview responses had been evaluated or how recruitment decisions had been reached. For example, interview forms contained the questions asked and applicants' responses, alongside notes regarding suitability, but did not always include a documented summary of the rationale for appointing candidates. While this did not impact on the provider's ability to recruit suitable staff, clearer recording would strengthen oversight and provide a more robust audit trail of recruitment decisions.

We raised these issues with the registered manager who was receptive to the feedback. They told us they would ensure recruitment interviews were robustly completed for future recruitment. We will follow this up at the next assessment.

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 to ensure people were protected from the risk of infection. Staff had received infection control training.

There were appropriate policies and procedures in place regarding infection prevention and control. Staff had a good understanding of infection‑prevention principles and were provided with appropriate PPE (Personal Protective Equipment) when required. One staff member told us, “We have more than enough PPE and can easily collect more from the office.” During our visit to the provider’s office, we observed a good stock of PPE available to staff. There was evidence that checks had been completed to monitor staff compliance with infection‑prevention and control requirements.

People and relatives told us staff always wore PPE when supporting them with personal care. A relative told us, “I am happy that they [staff] are wearing all the correct gloves and aprons and the standard of hygiene is satisfactory.” Another relative told us, “They [staff] are very hot on hygiene. They wear gloves, masks and aprons and regularly wash their hands.”

Where staff had received feedback during spot checks for improvements in infection, prevention and control (IPC), These were recorded, monitored and action immediately and where appropriate, staff were given extra training and support.

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 provider used electronic systems to record medicines administration and care provided, supporting accurate record-keeping and oversight. However, medicine-related information recorded in daily notes was not always reflected on individual medicines records. This meant staff may have needed to review multiple systems to identify concerns, reducing assurance that medicine-related issues could be identified and acted on promptly.

PRN (as required) medicine protocols did not consistently provide staff with sufficient guidance to support safe administration.

Protocols failed to capture detailed information, including the circumstances in which medicines should be administered, how their effectiveness should be monitored, expected outcomes, and when concerns should be escalated to healthcare professionals. For example, one person was prescribed glyceryl trinitrate (GTN) spray, a fast-acting medicine used to relieve angina (chest pain caused by reduced blood flow to the heart) however, there was no PRN protocol in place to explain when the medicine should be administered, where it was stored, what action staff should take if it was ineffective, or when emergency medical assistance should be sought. This increased the risk of inconsistent medicines management, delays in responding to deteriorating health needs, and people not receiving timely or appropriate treatment during a potential medical emergency.

Medicines management audits were not sufficiently robust to identify and address these shortfalls. As a result, the provider had not identified gaps in medicines information and guidance prior to the assessment. The provider acknowledged the feedback and confirmed they would implement stricter oversight and auditing of medicines management processes.

Records showed staff had completed medicines training and medicine competency assessments to help ensure they [Staff] administered medicines safely. Spot checks on staff practice were undertaken and recorded to identify any issues with medication administration techniques.