Passion 4 Care

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 good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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 demonstrated a proactive and positive approach to learning from accidents, incidents, and concerns. Events were recorded and investigated, and lessons were learned. Learning was shared with staff to promote continuous improvement.

The provider carried out various other checks to analyse and review people’s support. However, these were not always effective in identifying where improvements were required, such as care documentation not being accurate and missing documentation. The provider was responsive to our feedback during the site visits and missing information was added to people’s care folders swiftly.

The provider kept records of accidents and incidents, and external support was sought when needed to keep people safe. For example, we saw action had been taken to make a referral to relevant health professionals following a person’s fall to reduce the risk of reoccurance.

Staff worked with people to plan and organise their care, together with partner organisations and relatives in ways that ensured continuity. The manager explained how they gathered information from partner organisations when supporting people. Senior staff completed reviews with people to ensure their needs were being met adequately. New staff were introduced to people, and information was shared with staff both electronically and in paper form. However, some systems in place were not effective in identifying inconsistencies between the paper-based records and the electronic records.

People’s care documentation was not always up-to-date and reflective of people’s current needs. This meant people were at risk of not receiving appropriate support. However, as staff knew people and their needs well, we did not find anyone had come to harm during our assessment.

Electronic monitoring systems were not always reflective of people's call times, and some calls staff had logged into appeared to overlap with other people's call times. This meant it was difficult to track whether staff were attending to people's calls at the correct times and for the correct durations. People and relatives we spoke with did not raise concerns about calls not taking place. However, some people or relatives told us some calls were later than expected but they were generally contacted about this. One person told us, “They stay for the full time, are generally on time, but on the very odd occasion when they are running late, they ring.” However, one person told us, “They need to ring me if they are running late as we worry.”

People and their families told us they were supported by staff who knew their needs well. One person told us, “I have [equipment] to help me get up. The carer’s do help me, and they are very good. I’m not uncomfortable at all.” One relative told us, “I trust them, they help me.” Another relative told us, “I’m impressed with the care.”

The provider worked with people and healthcare and social care partners to understand what being safe meant to them and the best way to achieve that. Staff were trained to recognise and report on potential harm or abuse and worked with people to improve their 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 told us they felt they were safe. One person told us, “Yes, I’m safe. I appreciate their help.” A relative told us, “[Person] is safe... [Person] would speak to me if [person] had any concerns.” Another relative said, “[Person] is very safe with the carers.”

The provider told us, “We always communicate with the local authority safeguarding team to escalate as need be.” We saw referrals had been made and information documented in relation to incidents of a safeguarding nature.

The provider worked closely with people to understand and manage risks in a way that considered their overall wellbeing. Staff delivered care that was safe and supportive, while also helping people maintain their independence and continue doing the things that mattered most to them. This person-centred approach helped ensure people felt safe and respected in their own homes.

Staff supported people with learning disabilities and autistic people in line with the principles of Right Support, Right Care, Right Culture. Staff received training to understand individual needs, promote dignity, and ensure person-centred, safe, and respectful care.

Staff were able to identify risks to people and raised them with management for external support. We saw referrals being made to occupational therapists and the resulting positive outcome of equipment being provided to support the person’s safety. A member of staff told us, “I feel that we all work together as a team; if there are any issues, I will call the office or the GP or the family to share.” Another staff member told us, “We are all working as a team with the professional and speak with the district nurse to monitor people with diabetes."

The provider was not always identifying and managing risks in people’s own homes. This included making sure equipment was in place and used appropriately to deliver care safely to people.

People and relatives told us they were satisfied with the way in which care staff supported them with their equipment. A relative told us, “Two [staff] come to get [person] out of bed safely and gently.”

The provider took into consideration people’s home environments and equipment people used to support them and this was included this in their care documentation. However, we noted inconsistencies in people’s care documentation in relation to what equipment people had in place as well as how people should be supported to use this safely. Some people’s care documentation was generalised and not person-centred around their environment. Although no one had come to harm, accurate information should be maintained to guide staff around how to safely support people with their equipment.

Staff knew people well and no concerns were identified around people’s equipment at the time of our inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who were supported with supervisions, meetings and personal and professional development. Staff worked together well to provide safe care that met people’s individual needs. This was demonstrated through their learning culture which included face to face and online training.

People told us they generally had consistent care staff at regular times and calls were not missed. One person told us, “Continuity of care is important, and I see the same carers on a regular basis. I feel safe and secure.” A relative told us, “Staff stay for the full time, are generally on time, but on the very odd occasion when they are running late, they ring.” Another relative told us, “Staff come on time and stay for the full half an hour; they care see, they care.”

The provider completed pre-employment checks. References and criminal records checks had been obtained before staff employment. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff told us they felt encouraged to develop their skills and improve their knowledge. One staff member told us, “I have grown in this company; I am [job title] and I am doing advanced training. I am not just at a standstill.” Another staff member told us, “Training is good, and it is useful; I learn something new every day.”

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 told us staff were using personal protective equipment (PPE) in their homes, including aprons and gloves. One person told us, “[Staff wear] aprons, masks (if a carer has a cold) and gloves.”

Staff had appropriate training in relation to infection, prevention and control as well as management completing spot checks on staff regularly.

Staff told us they were aware of infection, prevention and control and what PPE was worn on every call as well as foot covers on some calls to respect the wishes and culture of the people they supported.

Improvements were needed to ensure people’s medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines appropriately. One relative told us, “The carer’s do [person’s] medicines. [Person] knows what they are on, and staff never miss.”

However, some records needed improving. Staff were recording medicine administration in people’s medicine administration records (MAR), however, we found a lack of protocols for ‘when required’ medicines. This meant people were at risk of not receiving their ‘when required’ medicines appropriately to support in maintaining their health needs. Although we found no harm had come to people as medicines had been administered correctly according to records. Medicines audits were being completed regularly. However, they were not always effective in supporting the identification of missing information or inconsistencies between care plans and MAR charts.

Records confirmed staff received medicines training as well as having regular competency checks completed. Staff were able to explain how they safely supported people with their medicines.