Because We Care Northampton

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 changed to inadequate.This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to risk management, safeguarding, staff recruitment and the management of people’s medicines. The service was in continued breach of legal regulation in relation to staff training.

This service scored 34 (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 demonstrate a learning culture that prioritised safety. Incidents and accidents had not been investigated to reduce the likelihood of them happening again or to identify any learning or improvements to people’s safety. Whilst staff completed incident forms, we were not assured that these were consistently completed, as not all staff had access to the online system used to record incidents. This lack of oversight and follow-up meant that opportunities to learn from incidents and improve safety were missed, placing people at risk of harm.

Systems to support safe care and continuity during transitions to other services was not always robust. Emergency grab sheets, which were essential for providing key information to other professionals such as emergency services, had not been completed. This posed a risk to the continuity of safe care in emergency situations. Leaders were aware of the importance of sharing relevant information, however, the absence of these documents meant that important details may not be readily available when needed. 

The provider did not adequately protect people from the risk of abuse or neglect. Safeguarding training was not up to date for both leaders and staff to ensure they had the necessary knowledge to identify and respond to safeguarding concerns appropriately. Leaders failed to recognise and act on potential safeguarding concerns including a missed call, unexplained bruising, and restrictions on people's choices. This lack of action placed people at risk and demonstrated a significant breakdown in the service’s safeguarding responsibilities.

The provider did not effectively manage risks to people’s health, safety, and wellbeing. Risk assessments lacked sufficient person-centred detail to mitigate identified risks to people. For example, risk assessments in place for people at risk of harm due to their health conditions contained limited information on how to reduce the risk. Additionally, not all risks to people had been assessed. For instance, there were no falls risk assessments in place for individuals known to be at risk of falling. This failure to identify and plan for individual risks placed people at significant risk of avoidable harm. 

The provider had systems in place to assess and monitor environmental risks within people’s homes, and leaders carried out initial assessments to identify and manage potential hazards. A person told us, “(They make me safe) by making sure my home is safe fire wise. The fire man came out and told me what needed to be changed. Making sure there is nothing I can trip on in the house and outside my garden and front door.” However, care plans required further improvement to provide detail on the maintenance requirements for equipment used in the delivery of care, such as stair lifts, to ensure equipment remained safe and functional.

The provider did not 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 been recruited safely, with missing recruitment checks identified, including Disclosure and Barring Service (DBS) checks, interview records, and references. Staff, including the registered manager and the director of the service (acting as the manager), had not completed the necessary training to carry out their roles safely and effectively. There were no systems in place to assess staff competence, such as spot checks or observations during care calls, and staff confirmed they had not been observed while delivering care. This lack of oversight and training placed people at increased risk of receiving unsafe care.

Infection prevention and control (IPC) practices required improvement to ensure people were protected from the risk of infection. Staff had access to personal protective equipment (PPE) to help prevent the spread of infections. However, not all staff had completed IPC training, to ensure they understood and followed safe practices. Additionally, there was no evidence that spot checks were carried out to monitor staff compliance with IPC procedures. Staff confirmed they had not been observed during care calls, meaning there was limited oversight to ensure correct infection control measures were consistently applied.

The provider did not make sure medicines were managed safely, placing people at risk of harm. People’s medicines were not always administered or stored in line with safe practice. For example, one person’s paracetamol was prompted or administered before the required four-hour interval. This placed the person at increased risk of overdose and the associated risk of harm. Documentation to support safe administration was not consistently available to staff, and records showed that staff had made additional entries on Medication Administration Records (MARs) due to delays in receiving the appropriate documentation. A staff member said, “Were always short of paperwork and it takes quite a while for things like that do get done.” These failings demonstrated a lack of oversight and unsafe medicines management practices.