Archived: 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 Inadequate. At this assessment the rating has remained Inadequate.

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

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

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 demonstrate a learning culture that prioritised safety. At the last inspection, we identified that incidents and accidents reported by staff were not being investigated by leaders, resulting in missed opportunities to prevent recurrence and strengthen safety and learning practices. Despite being aware of the required improvements, the provider was unable to evidence improved oversight in this area. During this inspection, we continued to find multiple reported accidents and incidents that had not been reviewed by leaders.

Systems to support safe care and continuity during transitions to other services were not always robust. Essential key information, such as emergency grab sheets for the emergency services, were not made available for all people using the service. This was also found at the last inspection. The continued absence of these documents meant that important details may not be readily available when needed, presenting a risk to the continuity and safety of people’s care in emergency situations.

The provider did not adequately protect people from the risk of abuse or neglect. Staff had completed safeguarding training since the last inspection to enable them to have the necessary knowledge to identify and respond to safeguarding concerns. However, the provider had not ensured they completed the level of training they needed to carry out their role as safeguarding lead effectively. The provider continued to fail to recognise and act on potential safeguarding concerns including ensuring that processes were in place to safeguard a person who had support with their finances.

The provider did not effectively manage risks to people’s health, safety, and wellbeing. Care plans and risk assessments were not consistently reviewed or updated despite known risks and previous inspection feedback. The provider did not always identify and assess risks to people. For example, staff undertook practices without the appropriate clinical guidance, increasing the risk of injury or infection to people. The provider did not effectively involve people or their families in understanding, planning for, or managing risks, which exposed people to avoidable harm. For example, staff encouraged a person to undertake activities independently without any documented risk assessment to ensure the person’s safety. People were placed at risk of harm due to the providers approach to risk management.

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 relative told us, “[The provider] got in touch with fire service to arrange a fire visit and the officer came and did full inspection of house.” However, risk assessments were not routinely updated to evidence that actions had been completed, such as installing a carbon monoxide alarm for a person. Monitoring processes also lacked clarity about who was responsible for ongoing checks and how frequently these should be carried out.

The provider did not always make sure staff received effective training, support, supervision and development. Improvements had been made to staff training since the last inspection. However, further improvement was still required to ensure all staff had completed the necessary training to keep people safe. For example, staff had not received formal training in safely using a device to treat life threatening allergic reactions for a person they supported.

People and their relatives told us they felt staff were knowledgeable and skilled in their roles. A person said, “I feel they know what they are doing. I don’t feel that any of them are incompetent.” Systems for assessing staff competence, such as spot checks and observations during care calls, remained inconsistent. A staff member said, “When you inspected us, [the provider] came and did a spot check a couple of days, but nothing since then.”

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 and staff had completed IPC training since the last inspection, to ensure they understood and followed safe practices. However, relatives did not always feel supported by leaders upon requesting staff wear additional PPE, such as face masks, to protect people from the spread of infections. In addition, whilst some spot checks were carried out to monitor staff compliance with IPC procedures, these were not routinely embedded into practice, 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. Significant concerns were identified in the provider’s systems and oversight of medicines management. For example, the inspection team found a person had missed their medication for 8 days due to a recording error. The provider failed to follow their own policies and procedures in ensuring medication administration records (MARs) were checked by trained staff. The provider failed to ensure safe systems for the administration, recording and monitoring of medicines and did not ensure staff had the required guidance or competency. Incident reporting, care planning, risk assessment processes and adherence to policy were inconsistent and in several cases absent, placing multiple people at risk of harm.