Gogomadu Cares Nottingham Office

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 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 safe care and treatment, good governance and fit and proper persons employed.

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 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.

Feedback we received from partner organisations stated they did not feel concerns they had raised were listened to and responded to.The provider had received complaints which they had recorded, and an outcome was also recorded but there was no evidence of how the service had changed to show learned lessons. We raised concerns at various stages of the assessment. During the early stages of our assessment in regard to safe and effective recruitment but were offered no further evidence or information by the provider of how issues including urgent concerns would be immediately addressed when these concerns were raised. Organisationally, lessons were not learned to help continually identify and embed good practice.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The provider had not established robust contingency plans to ensure people received the support they required in the event of all emergency or unforeseen events, such as a breakdown in the management of the service, bad weather, extreme staff shortages, or road closures.

There was no information to highlight who the service would contact for support such as if the person could be supported by family members and how contact would be made. There were numerous managers employed by the service but during our assessment many were unavailable, which left the registered manager who was also the nominated individual and a director at the service. Therefore, if the registered manager was not available, the service lacked a clearly documented continuity plan.

The person, with the help of staff took their care plan with them wherever they went, in case of an emergency, for instance if they needed to go to hospital. However, the person’s care plan had contradicting information, which could cause a delay in care or confusion to other services such as a hospital, to provide timely treatment. This put people at risk of not receiving the care they required in the event of an emergency or unforeseen circumstance.

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 bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider did not share concerns quickly and appropriately.

People using the service were not adequately safeguarded from harm. Systems in place to identify, respond to, and report safeguarding concerns were ineffective. Records showed that safeguarding incidents and concerns had occurred but were not consistently recognised, escalated, or reported to the local safeguarding authority or notified to the Care Quality Commission as required. The safeguarding policy lacked crucial information needed. For example, it did not cover all types of abuse, key safeguarding risks, or relevant contact details for referrals. This meant risks to people were not appropriately managed, monitored, or learned from. Poor oversight of this placed people at risk of harm.

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.

Guidance for staff on how to manage people’s healthcare needs was not always available to staff as it was not included in the care plan or daily notes. Changes to people’s needs were not recorded in a way which gave staff clear information regarding the most significant risks. Where care was refused, there was no recorded follow up or discussion on the impact this could have on the person’s health, so they were not actively involved in managing the risk of the decision.

Risks to people’s wellbeing were not always monitored. The risk assessments in place had identified some risks but did not evidence the involvement of the person or, their family. Some risk assessments were electronic, and some were paper copies, for example their flammable emollient cream risk assessment was not included within the care plan with the other risk assessments. Some risk assessments were incorrect or out of date and did not include some key parts of the person’s care. Weight had not been recorded for the person in over a year, and their height had not been recorded. Recording weight and height is vital to safely assess and manage risks such as malnutrition, pressure damage, and moving and handling needs. This person was unable to record their weight or height without the assistance of staff. This meant there was a risk staff would not be aware of essential information to manage risks and involve the person in risk information and management.

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.

Information regarding the equipment people required to support them with their care was not always clearly identified within their care plans, and there was no guidance for staff on the safety checks they should undertake prior to using equipment. For example, the person had a PEEP (Personal Emergency Evacuation Plan) in place; however, actions identified within the plan, such as measuring door widths, had not been followed up. It was unclear whether staff were expected to evacuate the person and how this would be achieved quickly and safely in the event of a fire in their home.

There was also no evidence that accidents and incidents related to the environment were being consistently recorded or reviewed to support learning and risk reduction. Although the provider had a fire policy and a health and safety policy, these lacked sufficient detail to guide staff practice. This meant environmental and equipment related risks may not be identified or escalated in a timely way, increasing the risk of delayed evacuation, injury, or harm to both the person and staff during an emergency.

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.

Recruitment files showed significant gaps in compliance. This included incomplete application forms, unexplored employment gaps, missing or unverified references, and references often obtained after staff had started work. Though the provider said staff would not work with people until these were obtained, they were not able to evidence this. There was no evidence of interviews for some staff, and no health information had been considered. One staff member had received a competency assessment which was completed by an unqualified staff member. The provider told us this was an administration error, but the staff member they said completed it also showed on their training records as unqualified. This had not been identified through reviews of the files, nor had any of the other issues identified. We found other examples where a different staff member had completed competencies with no evidence supplied of their own training and a staff member with gaps in their training conducted spot checks on other staff.

There was no evidence that staff were safely trained. This included for complex care needs and medicines. The service did not have any people accessing the service with a learning disability, autistic people, or people with dementia, at the time of our assessment but there was limited information that they would be able to effectively support these specialist areas if needed.These significant shortfalls meant leaders could not be assured staff had the right character, background, or experience to work safely, or were suitable for their roles. The failure to follow safe recruitment procedures represented a serious breach of legal requirements and left people at risk because unsuitable individuals may have been employed without appropriate checks. This meant staffing at the service could not be considered safe, and people were not protected from avoidable harm.

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.

Dressings were not consistently used and changed according to instructions. Failure to change skin dressings as required increases the risk of infection, delays wound healing, may cause further skin damage, and reduce the opportunity to identify and respond to wound deterioration, placing the person at risk of harm.Feedback about the environment cleanliness was mixed; however, discussions with the provider indicated that actions were being taken to manage this appropriately, taking into account individual needs, staff safety, and family involvement.

Staff training records we reviewed showed not all staff had received infection control training, including staff who did spot checks and competency assessments of staff. Where records showed it had been completed, it was done on the same day as 12 other courses, limiting the effectiveness of the training. However, feedback from a person using the service and a relative indicated that staff wore personal protective equipment (PPE) when required and they felt this was an area of strength from staff, to help keep the person safe.

The provider did not ensure that medicines and treatments were managed safely or in line with people’s individual needs, capacities, or preferences. Medicines management practices were not followed consistently in accordance with best practice, national guidance, or the provider’s own policies.

Care plans, daily records, and Medication Administration Record (MAR) charts did not consistently and accurately reflect all prescribed medicines. Information such as the purpose of medicines, dosing instructions, and key safety considerations was missing or unclear. MAR charts contained outdated, inconsistent, overwritten, or incomplete entries. Not all prescribed medicines, including ‘as required’ (PRN) medicines, were reliably recorded. The use of mixed handwritten and non-pharmacy MAR charts further increased the risk of error, as some entries were unclear, lacked authorised signatures, and could not be effectively audited. Where typed entries were used, these did not consistently identify the author.

Topical medicines were not managed safely. MAR charts did not clearly state the indication for prescribed creams or where they should be applied. Creams prescribed for twice-daily use were not always offered in line with instructions. These significant shortfalls increased the risk of ineffective treatment, discomfort, deterioration in skin integrity, and potential infection due to inconsistent or incorrect application.

The provider did not consistently record or follow up on medicines that were refused. There was limited evidence that refusals were re-offered, reviewed, or escalated in line with the provider’s own policy. Where refusals were documented, the reasons were often unclear or absent. This lack of oversight increased the risk that people missed essential treatment without appropriate clinical review, which may result in unmanaged symptoms, deterioration in health, or prolonged discomfort.

We identified examples of dosing errors that had not been recognised or acted upon by the provider. In addition, there was no robust system in place to monitor opening dates for medicines with a limited shelf life.

These failures placed people at risk of receiving medicines that were unsafe, ineffective, or expired, increasing the likelihood of harm. The provider did not demonstrate effective systems, oversight, or governance to ensure medicines were managed safely, accurately, and in a way that met people’s needs, resulting in an increased risk to people’s safety and wellbeing. Improvements were implemented after our assessment.