Archived: East Anglia Domiciliary Care Branch

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 provider was previously in breach of legal regulations in relation to safe care and treatment, staffing and safeguarding. Improvements were not found at this assessment, and the provider remained in breach of these regulations. Additionally, the provider was in breach of regulations relating to staff recruitment.

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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always identify and raise concerns and complaints on safety issues so they could be investigated and resolved. Due to this, lessons were not learnt to identify and embed good practice.

Relatives spoken to felt they may be listened to if they raised concerns or made suggestions, but these would not necessarily be implemented. Others told us they had lodged complaints about such things as agency staff using their mobile phones and out of date paper copies of care records for staff, including agency workers, to be trained on. The complaints log submitted as part of the assessment did not have any complaints logged on it. We had also found examples of out-of-date printed copies of care records in some homes. Lessons were not being identified from events such as complaints and learning from these had not been implemented across all homes.

The provider did not always work well with people to respect their rights within their home, as part of the transition for a new person. There had been an assessment completed prior to the person’s move with health care professionals and relevant parties but we were told by relatives there had been no discussions and consent with the people who lived in the home or their relatives about the new person moving in. This was against the Real Tenancy Test and Reach Standards which stated people should choose who they live with and for a tenancy to be genuine the tenant should have control over who they live with.

The provider did not work on improving people’s lives so they were protected and lived in safety, free from abuse, avoidable harm and neglect. Staff did not have the experience and knowledge to understand about restrictive practices and how to identify them. We found practices which were not legally justified, proportionate and necessary or as a last resort. Staff did not have an understanding of Deprivation of Liberty Safeguards (DoLS). Some told us these were in place for some people. Care records also stated this for some. However, we confirmed with locality manager there were no authorisation under DoLS for any person within the service. One person pulled their hair out, with a trigger being identified as they could be anxious or bored. To help stop with this they had their haircut short and wore a large headscarf. Their capacity had not been assessed for this or a decision made in their best interests. For other people legally justified restrictions had been removed without the risks being appropriately assessed and managed, so putting the person at risk of harm. One person lacked capacity and there was a best interest decision for the food cupboards, fridge and freezer to be locked as they would overeat and help themselves to food. The locks had been removed. The measure to stop them was for staff to be in their vicinity at all times and for staff to search their room for any food they had hoarded. They did not have sufficient staff on a 1:1 basis or extra working in the home to facilitate staff being with them all the time. There had been no further capacity assessment or best interest decision to look at these new measures which they had not identified as restricting.

People did not receive consistent support from staff to manage risks associated with their health and wellbeing. This was because there was a lack of written consistent guidance for staff and staff were not always knowledgeable about risks, including catheter, epilepsy and positive behaviour support. One person was at risk of overeating and helped themselves to food from cupboards, fridges, and bins had 3 risk assessments, a care plan and other documents. However, these had inconsistent details on what the risks were and what support they needed. One staff member we spoke to said there was no risks for this person and they just liked to eat a lot. Another staff member raised concerns regarding the lack of measures in place to support the person who had choked in the past and would eat raw as well as cooked food. There was no epilepsy care plans for those people who suffered from this. The national guidance published by the National Institute of Clinical Excellence (NICE 217) on reducing the risk of epilepsy related deaths, including sudden unexpected death in epilepsy, by using a nighttime monitor was not incorporated in people’s support plans even if they were known to have seizures at night.

The provider did not always detect and control potential risks in the care environment. They did not make sure all risks were identified and appropriate measures put in place or escalated to the landlord when required. We visited a home and identified there was an uncovered radiator in a narrow shower room, which was a risk because of an exposed hot surface. There were no environmental risk assessments for this home and it had not been picked up via the health and safety audit, even though this was a specific question prior to our visit. The health and safety audit following our site visit said the radiator would be turned down as a mitigation. We visited a home where the landlord had removed all the fire extinguishers. We checked the provider’s fire emergency plan to ensure appropriate measures had been put in place. However, the plan said the home was flats, near a main building which was linked to a fire station and there were fire extinguishers in place. The home was a bungalow, not near a main building and was nowhere near the fire station it said it was linked to. In another home a summer house had been left collapsed in the garden since the previous summer. One of the people who lived at the home had a visual impairment and was blind. This impacted on them accessing the garden as they had to be supervised due to the trip hazard. This was not identified on their environmental risk assessment or as a risk for individual person it affected.

The provider did not make sure staff were all sufficiently skilled and experienced to meet everyone’s needs. The provider’s recruitment and selection procedure was not always followed to ensure appropriate steps were taken to ensure appropriate candidates were employed. Full employment history and work placed references were not always obtained.

There had been high use of agency staff within the homes. The provider did not have oversight of exactly which agency staff were working at which homes, if they had received agency profiles and if agency staff had the correct training, had completed their induction and were risk assessed to work in the home. We asked for documents and details for agency workers for specific homes. For 1 home we were told by the locality manager they were not using any agency workers. From our site visit we identified 5 agency workers and from the rota another who had not been identified by the manager. The manager had also sent an agency profile and risk assessment for 1 worker who had been working at the home. This put people at risk of harm from agency workers who did not have skills and training to meet their needs.

Staff did not always have the skills or training to meet people’s needs. For example, no staff had undertaken fire marshal practical training. This meant they may have not have knowledge or skills to respond appropriately in the event of a fire. In one home people needed support with catheter care, medication support and epilepsy. Out of the 4 staff 1 was not compliant with catheter training, 2 were not compliant with epilepsy and only 1 was up to date with their medication training and competency. This put people at risk of harm from staff not trained to meet their needs.

The provider did not always assess or manage the risk of infection and ensure appropriate infection prevention and control measures were in place. We visited a home and identified they had Control of Substances Hazardous to Health (COSHH) items, such as toilet cleaner, descaler and disinfectant in the downstairs toilet. The Service Lead told us they should have been locked away. There was no COSHH risk assessments in place which was not following the Provider’s COSHH Policy. The homes had appropriate stocks of personal protective equipment (PPE). There was e-learning training on infection prevention and control which had been completed by most staff.

The provider did not always make sure medicines were safely managed or that treatments were safe and met people’s needs, capacities and preferences. People were not always involved in assessment and reviews of their medicines. People’s medicines care records did not contain details about the medicines, including side effects, or the support people needed with these. As and when needed (PRN) medicines protocols were not always in place. Some lacked detail about what should be tried before the PRN medication was given and not all were signed by the prescriber. We visited a home where a person was receiving a topical medication of ear drops once a week. The medicine had an opening date of 8 September 2023, with instructions to discard 4 weeks after opening but this was still being used. The same home had a medicated cream which did not have a date of opening. This had been identified at the medication audit prior to our visit and was still an issue at the medication audit after our visit, so no effective actions had been taken.

Norfolk County Council informed us of a safeguarding referral for a medicines error which had been substantiated. They said there was a lack of details on the referral so they could not identify if it was a missed dose, an overdose or not correctly counted. We checked the staff identified in this error and found they were overdue for a medication competency at the time of the incident.

We found homes visited used different paperwork and processes for the management of medicines. Some used topical medicine administration records (TMAR) for creams, some used medicine administration records (MAR) for creams and some recorded on both forms. Some used body charts of where to apply creams and some did not. We identified for one home who used both MAR and TMARs for creams, inconsistency between how many times in one day the cream had been applied between the two forms, with one stating twice and one starting three times in a day.