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South Norfolk Carers Limited

Overall: Inadequate read more about inspection ratings

Amelia House, Norwich Road, Brooke, Norwich, Norfolk, NR15 1HJ (01508) 558218

Provided and run by:
South Norfolk Carers Limited

Report from 9 October 2024 assessment

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Safe

Inadequate

Updated 16 January 2025

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection, 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 medicines, risk management and safe and effective 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.

Learning culture

Score: 1

The service 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 fully investigate safety events. Lessons were not learnt to continually identify and embed good practice. People and their relatives told us when they raised safety concerns, these were either not listened to, rejected, or initially acted upon but then rectifying actions withdrawn. One relative told us about the concerns they had about safety and how this negatively impacted on their family member’s mental and physical health. They told us, ‘I have spoken to the [registered] manager lots of times, but things don’t improve.’ Staff agreed that communication regarding safety incidents was poor and that they were often not aware of them. The records we viewed did not consistently show there was a proactive culture in place regarding safety incidents or concerns and that these had been effectively reflected upon and used to drive improvement.

Safe systems, pathways and transitions

Score: 1

The service did not work consistently well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. People told us they did not always receive continuity of care and that this negatively impacted on their health, safety, and wellbeing. This was because people did not consistently receive care from the same small group of staff who knew their needs, risks, likes, dislikes, routines, and preferences. Staff agreed with this and one staff member told us, ‘I find it difficult watching how distressed some people who use the service can get [about lack of consistent staff] and the fact they are not listened to by management.’ Records showed that people’s safety, in relation to risk, was not always identified, monitored, recorded, or mitigated. For some people, their hospital passports contained inaccurate or incomplete information which risked them receiving a lack of continuity of, or inappropriate, care in the event they needed hospital medical treatment.

Safeguarding

Score: 1

The service did not work consistently 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 avoidable harm and neglect. They did not always share concerns appropriately or work in an open and transparent manner. The provider had failed to understand the impact the poor quality of service was having on people meaning they were at risk of neglect and avoidable harm. Records showed that whilst some concerns of a safeguarding nature had been raised with the local authority as required, we found incidents where advice should have been sought to ensure people were fully protected.

Involving people to manage risks

Score: 1

The service did not work well with people to understand and manage risks. They 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 and their relatives told us they did not always feel safe using the service due to not all staff knowing their needs or having the skills to meet those needs. Staff also raised concerns about the management of risk due to some staff not knowing or understanding people’s needs, including in relation to risk. The records we viewed demonstrated that risks had not been consistently identified, recorded, managed, mitigated, and/or reviewed.

Safe environments

Score: 1

The service did not always detect and control potential risks in people’s own homes. Records showed that not all environmental risks in people’s own homes had been fully identified, recorded, mitigated, and/or reviewed to ensure people, and staff’s, safety. For example, we found risk assessments that had identified risk factors in the care environment but had failed to provide staff with information on how to mitigate them. We also found that the risks associated with fire in people’s homes had not been fully or robustly recorded or mitigated; this included in relation to the use of emollients. Emollient use can increase the risk of severe injury or death through fire due to their flammability.

Safe and effective staffing

Score: 1

The service 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 told us they were not consistently supported by staff who had the appropriate skills, experience, competency, or training to meet their needs in a safe and person-centred manner. One relative told us, ‘New carers don’t understand my [family member’s] needs and often don’t know how to use equipment.’ The records we viewed confirmed not all staff had received regular training, supervisions, competency assessments, spot checks and appraisals. The staff who provided us with feedback agreed they did not receive the support or training required to help them effectively perform their roles.

Infection prevention and control

Score: 2

Whilst the service had not assessed the risk of infection for each person who used the service or completed a recent infection prevention and control audit, most people we spoke with did not have concerns in relation to infection management. The provider had an infection prevention and control policy in place and this referred to best practice guidance.

Medicines optimisation

Score: 1

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences, and the service could not demonstrate that people had received their medicines as prescribed or in line with best practice guidance. The service could not demonstrate that people had received their medicines safely, as prescribed and in line with best practice guidance. We found multiple omissions in medicines administration record (MAR) charts and the service had no robust system in place to manage the application, removal and rotation of transdermal patches which are medicines applied to the skin in the form of a patch. Where the service had sought approval from a health professional on the administration of medicines contrary to the prescriber’s instructions, this had not been robustly recorded with documents amended to reflect the change. All of these shortfalls placed people at risk of harm from medicines errors and whilst people’s medicines were being regularly audited by the service, these had failed to identify the concerns.