Mr 'C's

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 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 people’s safe care and treatment, person-centred care, safeguarding, good governance and staffing.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems for the management and oversight of safety incidents were ineffective. Significant incidents were not consistently documented, reviewed or escalated. For example, in relation to a person who became unwell due to their diabetes. This meant action was not always taken to protect people from harm or reduce the risk of similar incidents occurring in the future.

The service did not demonstrate an effective learning culture that promoted safety and continuous improvement. Processes for reviewing accidents, incidents and safeguarding concerns did not reliably identify risks, support learning or drive improvements in care delivery. Analysis of accidents and incidents was incomplete, trends were not effectively monitored, and care plans were not routinely updated following incidents or changes in people's needs. Some staff told us where they had made suggestions or raised concerns and these had not been recorded, acted on or mitigated.

Although the provider had identified actions to strengthen the learning culture within the service, including the use of staff supervision to improve practice and oversight, these actions had not been implemented. This meant opportunities to improve the safety, governance and the quality of care were missed.

The provider did not work effectively with people, relatives and health and social care partners to establish and maintain safe systems of care. Systems were not in place to consistently monitor and manage people's safety or to ensure continuity of care, particularly when people moved between services.

The service did not ensure care pathways, admissions and transitions were planned and coordinated in a way that promoted people's safety and wellbeing.

People did not always experience coordinated transitions into the service. One person told us they had been discharged from hospital and brought to the service 4 months previously without access to their money, clothing or personal belongings. They were unable to tell us where the keys to their home were and did not know what arrangements had been made for their future care and support. This demonstrated a lack of planning and communication during the transition process.

Staff worked with GP’s, district nurses and other specialist services to support some people with complex needs. However, systems to ensure effective multidisciplinary working were not sufficiently robust. Care plans and risk assessments were not consistently reviewed when people's needs changed, and significant incidents and deteriorations in health were not always reflected in care records. As a result, staff could not be assured they had access to accurate and up-to-date information to guide safe care.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Oversight of safeguarding was ineffective. The provider's safeguarding records were incomplete, lacked sufficient detail and did not evidence actions taken, outcomes achieved or lessons learned. Information provided by the local authority showed the service had made multiple safeguarding referrals which had not been recorded in the provider's safeguarding monitoring records or notified to CQC. This included concerns relating to a person who developed a Grade 4 pressure ulcer and another person who was found lost and disorientated in the community.

These failings meant the provider could not demonstrate effective safeguarding governance, learning or assurance and could not be assured people were protected from abuse, neglect and avoidable harm.

Leaders told us they worked with the local safeguarding team and staff understood how to report concerns. Staff we spoke with were able to describe safeguarding reporting processes. However, people were exposed to the risk of avoidable harm because safeguarding concerns were not consistently identified, escalated, recorded or reported. The provider failed to make safeguarding referrals and statutory notifications to CQC (Care Quality Commission) in line with legislative requirements.

For example, care records for one person contained 2 undated body maps recording multiple injuries, including bruising and skin tears. Although staff stated these injuries had been noted following the person's return from hospital, no safeguarding referral had been made. As a result, the provider could not demonstrate the injuries had been appropriately investigated, or actions had been taken to protect the person from further harm.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The manager told us there was nobody living at the service requiring DoLS at the time of this assessment.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were placed at risk of harm because identified risks were not consistently assessed, monitored or managed. Where risks had been identified, appropriate guidance was not always in place to support staff to deliver safe and effective care. For example, one person's risk assessment referred staff to a behavioural support plan to manage risks associated with verbal aggression and self-neglect arising from a brain injury; however, no behavioural support plan was available. This meant staff did not have the information required to provide safe, consistent support during periods of distress. One staff member said, “The care plans and risk assessments are so-so – they are ok, I don’t think there is much communication with staff, so they are updated but we don’t have the time to sit and read them.”

Oversight of care records was ineffective. Daily care records contained significant gaps and did not demonstrate care and support had been delivered consistently. Records for people living with dementia showed multiple days where no care had been documented, meaning the provider could not evidence people's needs had been met or appropriately monitored.

Monitoring of health risks was also inadequate. Records did not demonstrate risks associated with constipation were being effectively assessed or managed. For some people, there were prolonged periods where no bowel movements were recorded, including a person receiving palliative care and people living with dementia. Although staff stated this was due to recording errors, the records available did not provide assurance appropriate monitoring had taken place or risks to health and wellbeing had been effectively managed.

People at risk of pressure damage were not consistently protected. Repositioning records were absent or incomplete for people who required regular turning and pressure area care. In one case, there was no evidence repositioning had taken place for more than 24 hours. This meant the provider could not demonstrate appropriate measures were consistently being taken to reduce the risk of pressure ulcers and other avoidable harm.

These concerns demonstrated ineffective oversight of care planning, risk management and record keeping and meant the provider could not be assured people were receiving safe and appropriate care.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

People were placed at risk of avoidable harm because the provider did not maintain effective oversight of health and safety systems within the service. Critical fire safety, water safety, environmental and equipment safety checks had not been completed consistently, were overdue, or had been inaccurately recorded, preventing the provider from demonstrating risks were being effectively managed.

Fire safety arrangements were inadequate. The fire alarm servicing was overdue, faults on the fire alarm system had not been identified by staff or the management team, and there was no evidence weekly fire alarm testing had been carried out for over a year. Emergency lighting checks, fire extinguisher checks and other fire safety records had been completed in advance, meaning records could not be relied upon. Personal Emergency Evacuation Plans (PEEPs) contained inaccurate information, fire door inspections had not been routinely completed, and a significant number of fire doors inspected during the assessment required maintenance. In addition, the provider could not demonstrate staff had received recent fire safety training. These failures increased the risk people could not be safely alerted to, protected from, or evacuated during a fire.

Water safety management was also ineffective. Required temperature monitoring checks had not been completed consistently, records had been completed in advance, and there was no evidence elevated water temperatures had been risk assessed or acted upon. Records relating to showerhead cleaning and Legionella monitoring had also been pre-dated. As a result, the provider could not demonstrate risks associated with scalding or waterborne infection were being effectively monitored and mitigated.

Other safety-critical monitoring systems lacked effective oversight. Window restrictor checks, gas safety records, carbon monoxide monitoring, call bell audits, portable appliance testing and bedrail checks were either incomplete, inaccurate or pre-dated. The gas safety certificate had expired, and there was no carbon monoxide detector in the boiler room. These failings meant the provider could not provide assurance essential safety equipment, environmental controls and monitoring systems were functioning effectively.

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

People were placed at risk because the provider had not ensured staff were suitably trained, competent, supervised or deployed to meet people's needs safely. New staff did not receive effective inductions, competency assessments were not consistently completed, and records showed significant gaps in mandatory training compliance. The provider could not demonstrate staff had completed the Care Certificate or received required refresher training in key areas including safeguarding, Mental Capacity Act 2005, moving and handling, fire safety, food hygiene and person-centred care.

The service supported people with complex needs, including dementia, diabetes, alcohol dependency and requiring catheter care; however, there was no evidence the majority of staff had received condition-specific training to equip them to recognise deterioration, respond to changing needs or escalate concerns appropriately. Staff confirmed they had received little or no formal training in several key areas.

Systems for staff supervision and support were ineffective. Staff were not receiving supervision in line with the provider's policy, records did not evidence regular supervision had taken place, and actions identified through provider audits to improve supervision arrangements had not been implemented. One staff member said, “No we do not have regular supervision. I have not had one for a while.” There was no effective system in place to monitor supervision compliance or staff competency.

The provider also failed to ensure staffing levels and deployment were sufficient to meet people's needs. Staffing dependency assessments did not provide assurance staffing arrangements reflected the current needs of the service, despite a significant number of people being admitted for short-term or respite placements. Records identified substantial shortfalls between required and planned care hours.

Staff consistently reported there were insufficient staff on duty, particularly at weekends and during night shifts. They said “No, there is not enough staff – itdoesimpacton the people as we do not geta lot oftime to sit with them” and, “Staffingis the main issue – weekends weare hungout to dry – justbecauseit is Saturday andSundayitis still a carehome.” Concerns included floors being left unattended during breaks, staff being diverted from care duties, delays in responding to people's needs and occasions where staff were required to manage emergencies alone. Although staff told us these concerns had been raised with the management team on multiple occasions, appropriate action had not been taken.

These failings demonstrated significant weaknesses in workforce planning, training, supervision and staff deployment, increasing the risk people would not receive safe, effective and person-centred care.

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.

The service did not always manage infection prevention and control risks effectively. Leaders described cleaning schedules, availability of personal protective equipment and dedicated domestic staff. Domestic staff demonstrated understanding of colour-coded cleaning systems and infection-control procedures. However, people were exposed to the risk of infection because standards of cleanliness and infection prevention and control (IPC) were not consistently maintained across the service.

Laundry arrangements created potential cross-contamination risks. There was also a strong odour of urine within the home, and concerns were identified regarding the management of risks associated with faecal incontinence.

Infection prevention and control practices were not consistently followed during medicines administration, placing people at risk of cross-contamination. During an observation of medicines administration, a staff member used the same medicines pot to dispense medicines for multiple people before handing the medicines to them to take. Appropriate hand hygiene was not undertaken between supporting each person. These practices did not reflect safe infection control procedures and increased the risk of transmitting infection between people using the service.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People were placed at risk of harm because medicines systems were not safe or effectively managed. Medicines were not always stored securely, medicines reconciliation processes were ineffective, and records did not provide assurance medicines had been administered as prescribed. Prescribed medicines were found in an unlocked room and had not been entered into the medicines management system, creating a risk medicines could be missed or administered incorrectly.

Medicines administration records (MARs) contained omissions, missing signatures and inconsistencies, meaning the provider could not always demonstrate who had administered medicines or whether medicines had been given correctly. Photographic identification was not consistently available on MARs, increasing the risk of medicines being administered to the wrong person.

There was insufficient oversight of medicines administration. Staffing records showed occasions where no medicines-trained staff were rostered on night shifts, and staff described unsafe practices to ensure medicines were given. The provider could not demonstrate appropriately trained and competent staff were always available to administer medicines safely.

PRN (as required) medicines were not always supported by clear protocols, resulting in a risk of inconsistent administration. In one example, a prescribed medicine intended for use when required was being administered routinely without sufficient guidance for staff. Medicines audits were ineffective, actions identified through audits had not been completed, and records contained inaccuracies, demonstrating poor governance and oversight.

Additional concerns were identified regarding medicines storage, temperature monitoring, staff competency and infection prevention and control during medicines administration. Records did not demonstrate medicines had been stored within recommended temperature ranges, staff administering medicines had not always received up-to-date training or competency assessments, and poor infection control practices increased the risk of cross-contamination.

These failings meant the provider could not be assured medicines were managed safely or people consistently received their medicines as prescribed.