Clover Healthcare

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.

This is the first assessment for this service. This key question has been rated 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.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff listened to concerns about safety, and when things went wrong, these were investigated and reported appropriately. Lessons were identified and shared with the team to support continuous improvement and embed good practice. Staff told us learning from incidents was shared with them in supervision, team meetings and other informal routes.

Staff understood the importance of learning from incidents, feedback and daily practice to improve the quality and safety of care. The registered manager had recently compiled a lessons learnt log, as they had noted this was not in place under the previous manager. Some of the issues we found during this assessment had already been identified by the registered manager and steps were underway to improve processes. Leaders encouraged reflection and, whilst there had not been any significant safety events, processes were in place to use information from safety events to strengthen systems, reduce risks and support better outcomes for people.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff and leaders demonstrated awareness of the importance of coordinated and safe care pathways. Systems were in place to share relevant information when people’s needs changed or when they moved between services, helping to ensure consistency and reduce the risk of errors or omissions. The registered manager told us they used a secure, encrypted messaging application to share information with staff when there had been an unexpected change in people’s needs before staff were able to read their updated care plans.

People’s care plans contained up to date emergency grab sheets to support a smooth transition to hospital should they suddenly become unwell. This supported staff to deliver care that was well-coordinated, consistently delivered and responsive to changes in people’s circumstances.

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.

Although staff understood safeguarding principles and people told us they felt safe with the staff who supported them, the quality of some documentation did not always support safe and robust decision-making. Mental Capacity assessments were not consistently completed to an appropriate standard and did not always demonstrate a clear assessment of the person’s ability to make specific decisions. Some people’s mental capacity had been assessed when there was no reason to suspect they lacked mental capacity to make a specific decision. In addition, where people were assessed as lacking capacity for certain decisions, records did not consistently show that best-interest decisions had been completed, or that these decisions involved the right people.

These documentation gaps meant the provider could not always evidence that people’s rights under the Mental Capacity Act (MCA) had been upheld or that safeguarding risks relating to consent and decision-making had been fully considered. While we did not find evidence of people being harmed, the absence of clear assessments and well-recorded best interest decisions increased the risk of inconsistent or unsafe practice.

When feedback was shared with the registered manager, they were responsive and understood what needed to be done to ensure safeguarding-related records consistently met expected standards and demonstrated that decisions are lawful, person-centred and protective of people’s rights.

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

During the assessment, we found limited evidence that people were consistently involved in their own risk assessments. Records did not always show that discussions had taken place with people about identified risks, or the steps taken to manage them. This meant that staff could not always demonstrate that people’s views, preferences and daily experiences had been considered when planning how risks should be mitigated.

However, relatives told us that their family members had been involved in discussions about their care and had agreed to their support plans. One relative said “[Person] was involved in drawing up the care plans. [Person] is mentally able so they would only speak to them. [Person’s spouse] was there too and they have Power of Attorney.” Relatives felt staff understood the person well and explained any changes in a way that helped the person remain in control of their care. This feedback indicated that, while involvement was happening in practice, it was not consistently reflected in the service’s written documentation, which reduced the provider’s ability to evidence person-centred risk management.

Overall, although people and relatives felt staff supported them safely and respectfully, the lack of consistent recorded involvement meant the provider could not fully demonstrate a person-centred approach to managing risks. Improvements were needed to ensure people’s voices and decisions were clearly recorded and used meaningfully in risk assessment and care planning processes.

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

There were risk assessments in place for specific tasks or interactions within people’s homes, such as safely emptying a commode and ensuring the safety of equipment being used. However, the service did not have one overall environmental risk assessment for each person’s home. This meant the provider could not always demonstrate a comprehensive or structured approach to identifying wider environmental risks that may impact people’s safety.

The registered manager was able to clearly describe what they look for when assessing environmental risks, and staff we spoke with understood what to be aware of when working in people’s homes. This showed that safe practice was generally understood and applied in day-today care. However, this knowledge and oversight were not consistently documented, which reduced the service’s ability to evidence a robust and systematic approach to managing environmental risks across all care settings. Because documentation was incomplete, leaders could not assure themselves that the environmental risks were consistently identified, reviewed or monitored over time. While we did not find evidence that people had been harmed, the gaps in record-keeping increased the risk of inconsistent practice and made it harder to demonstrate that environmental safety was being managed proactively.

Improvements were required to ensure environmental risk assessments are completed in a structured and consistent way, accurately recorded, and used to inform safe and person-centred care planning.

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

On the whole, staff were recruited safely. Pre-employment checks were completed for most staff, including Disclosure and Barring service (DBS) checks and verification of identity and employment history. However, some staff only had one reference on file, which meant recruitment records were not always fully completed in line with safe recruitment guidance. The registered manager had already identified this issue before the assessment and had taken steps to improve recruitment practices and ensure future files contained two appropriate references as standard.

Staff received training relevant to their roles, and training records showed that courses were up to date. This included training that met the requirements for supporting people with a learning disability or autistic people, in line with current standards. Staff told us they felt confident in their roles and ability to meet people’s needs. One staff member said, “I have received training in safeguarding, health and safety, moving and handling, first aid and person-centred care. I feel confident to support someone with complex care needs.”

However, despite staff being suitably trained, the gaps in recruitment documentation meant the provider could not consistently demonstrate that all staff had been fully vetted prior to starting work. This reduced the level of assurance around staffing safety and meant additional improvements were required to ensure recruitment systems consistently met expected standards.

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.

Staff followed appropriate hygiene practices when delivering care in people’s homes and understood their responsibilities in preventing and controlling infection. Training records showed that staff had completed up-to-date training relevant to infection control, and staff told us they felt confident in applying this knowledge in practice. One staff member told us, “I follow hygienic processes, [including] the use of PPE (personal protective equipment), washing hands regularly, cleaning equipment and following procedures to prevent infection spread.” A relative said, “staff always wear aprons and gloves.”

The provider ensured staff had access to suitable protective equipment and guidance, and people told us they felt staff maintained good standards of cleanliness and hygiene when providing care.

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.

On the whole, medicines were managed appropriately. Staff understood how to administer people’s medicines safely, and relatives told us they had no concerns about how medicines were handled or given. People said they felt confident in the staff who supported them, and records showed that routine medicines were administered as prescribed.

We found protocols for as-required (PRN) medicines lacked sufficient detail. They did not always clearly describe the signs and symptoms staff should look for, when PRN medicines should be offered or administered, or any specific guidance tailored to the individual. This meant staff did not always have the information they needed to make consistent and well-informed decisions, increasing the risk of inconsistent practice.

Despite these documentation gaps, staff we spoke with were able to describe how they ensured medicines were administered safely, and relatives confirmed they felt their family members received medicines correctly. One relative told us, “I think staff are very keen to do everything right.” Whilst this helped reduce the immediate risk to people, clearer and more robust protocols are needed to strengthen governance and ensure staff have the guidance required to support safe and person-centred medicines management.

Improvements were required to ensure PRN protocols include person-specific instructions, clear threshold for administration, and guidance on when to escalate concerns or review the need for these medicines.