Housing 21 - Anvil Court

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• 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

Systems were not in place to ensure people were kept safe from harm. Safeguarding concerns were not adequately followed up to prevent reoccurrence. Care plans and risk assessments were not updated regularly meaning the care they received was not reflective of what was recorded in their plans. There was a high use of agency staff, especially at night, which had caused shortfalls in the quality of care being delivered due to a poor induction into the service. However, there were safe infection prevention and control practices in place.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The majority of people and relatives we spoke with had not experienced any concerns such as accidents or incidents. One relative told us under the previous management things had been dealt with well although it was now more difficult to get hold of anyone. One person gave an example of where they had been supported by staff to change their wheelchair as they no longer felt it was safe. Although people and relatives we spoke with did not raise concerns regarding the way in which accidents and incidents were managed, we found people were placed at risk due to concerns not being reviewed and acted upon to minimise the risk of this happening again.

Staff did not feel incidents and accidents were acted upon by the management team, One staff member said, “On handover staff may give us information of falls. Its verbally and certainly if they have infections it’s not recorded. Its written but no one is doing anything.” Another staff member said, “We report things that happen and nothing gets done.” The management team acknowledged more needed to be done to ensure concerns were followed up on. They told us that although concerns were reported they were not always fully reviewed and recommended actions were not always shared with staff.

Systems were not effective in monitoring accidents and incidents to ensure lessons were learnt. When staff submitted accident and incident forms these were logged on a central system. However, there was no evidence of how these had been reviewed, no trends analysis completed, and no record of what action had been taken or shared to mitigate the risks. The service log of incidents and actions taken which should have been updated monthly had not be completed for over a year. This meant concerns including repeated falls, medicines errors and health concerns had not been comprehensively reviewed and records updated. The failure to ensure lessons were learnt from accidents and incident meant there was a risk of them happening again. This was a breach of Regulation 12 (Safe care and Treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed responses regarding how safe people and their relatives felt the service was. One person told of an incident where they had felt vulnerable, cold and frightened as staff had left them undressed and on the edge of their bed. They told us they did not know when staff would return. Although they had reported the incident to staff and the management team no action had been taken and no response given. Another person told us they were concerned that agency staff had entered their flat without them knowing and written their notes without any interaction. They told us someone being in their flat without their consent when they were asleep had left them feeling vulnerable. Other people told us they felt safe with staff. Comments included “Staff are all very nice. I feel safe, they are normal like me” and “Our carers I feel 100% safe with.”

Staff had completed safeguarding training and were aware of the different types of safeguarding concerns. A staff member told us, “We do look out for things all the time and listen to what they say regarding money. We have a handover book we would report in and in their file and have a list of phone numbers we can contact” Despite staff being aware of safeguarding procedures we found that staff had not always ensured concerns were reported. We spoke with the regional management team who assured us these concerns would be investigated and systems reviewed to ensure concerns were reported in line with requirements going forward.

People were not always protected from the risk of abuse as robust safeguarding procedures were not always followed. We identified a number of safeguarding concerns including concerns regarding staff practice, allegations of missed calls, medicines errors and an altercation between two people. These had been reported to the local authority although systems had not always ensured follow-up action was robust. The regional manager acknowledged these concerns, and regular meetings were being held with the local authority to discuss issues arising in the service. The regional manager gave assurances these incidents would be reviewed.

People and their relatives gave mixed responses regarding how staff managed risks to their safety. One person told us they were worried they did not have a care plan in place as it had been taken away and not returned. Relatives told us of instances where they food had not been prepared appropriately, showers not provided and records of care not matching with what support had been provided. Other people told us they felt staff knew their needs and provided their care with kindness.

Staff told us they did not have the most up to date information and guidance regarding people’s needs and risks to their safety. They told care plans were not updated and agency staff did not have the correct information to work from. Staff told us of one person who experienced a lot of pain in the evenings and wished to go to bed early so they were more comfortable. However, this wasn’t reflected in the persons care records and the persons calls were scheduled later than they wished. One staff member told us, “We sometime get temporary care plans and it can take a while to get the proper care plans. Some care plans out of date, but we will put a note onto the management. This could be a risk due to agency not knowing people as well as we do.” Another staff member said, “Some [care plans] are a bit out of date, they could have moved on and need more help. Agency won’t have the most up to date information.” Managers told us they were aware of these concerns and were looking at different ways to update records. They acknowledged this needed to be prioritised so records accurately reflected people’s needs and staff had the correct guidance to work to.

Risk assessments were not updated on a regular basis and did not reflect people’s current needs. Where there had been significant changes in people’s mobility and the risk of falls, care records had not been updated to reflect this. The lack of guidance in relation to changes in people’s health care meant staff were not always aware of their needs and how to support them. For example, one person’s mental health needs had not been recorded within their care records despite them becoming extremely anxious on a regular basis. Health care guidance given for two people was not included within their care records. This meant there was a risk the correct emergency protocols may not be followed as required. Following the inspection, we were sent updated care plans and risk assessments for review. However, we found these continued to lack important information regarding people’s safe care and well-being. The lack of up-to-date information for staff was of particular concerns due to the high level of agency staff used within the service who were reliant on people’s care records for information about the care and support they required.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed responses from people and their relative in relation to staffing numbers. One person told us, ““SStaff don’t stay for the full length of the call, this morning they did but that’s because you are here. Before that, for my 15-minute call they are here 4-5 minutes.” As reflected in other areas, there was a concern regarding the high number of agency staff being used. One person told us their loved one’s care call had been missed and they needed to call staff to ask for their help. People felt they were supported well by regular staff but shared concerns regarding the competence of agency staff, their knowledge and skills. Due to the number of agency staff being used to support people this was having a significant impact on their well-being and trust in the service. One relative said, “Employed staff have the skills, agency is very poor quality. Its simple things like not giving [person] her support to brush her teeth or picking up the fact it’s a cold day and I go in and [person] has no tights on. The regular staff don’t miss this detail but agency staff do miss the details.” A person told us, “The carers are bloody brilliant but the agency I am disgusted with. They are not given training.”

Staff told us they felt under pressure due to the staffing concerns within the service. They told us they did not feel the rota was managed well and there were regular occasions when they were running shifts with less than the allocated staff numbers. The use of agency was also a significant concern for staff as they did not feel they had the skills and knowledge they required. One staff member said, “We have to use agency staff – especially at weekends. They don’t know people and they don’t read the care plans, so we have to send them back in. We do have the odd day when staff are sick, or agency don’t arrive. We have all been here a long time, so we work well together. We can rely on each other.” Another staff member told us, “Sometimes it’s just three of us on and agency don’t turn up. We have a staffing problem, full stop.” Staff did not receive supervision on a regular basis. One staff member told us, “I have only had 3 since I have been here in 4 years. I cannot remember when I last had one. They are useful for feedback if we had them.” Another staff member said, “It keeps being mentioned and I have said to just book it in on my rota but it hasn’t happened yet. It’s well over a year since I had one.” We spoke with regional team who acknowledged the concerns people and staff expressed regarding agency use. They told us they were working hard to recruit new staff and had plans in place to provide temporary cover for the service. They told us a programme was in place for updating face to face training and we saw evidence this had been arranged.

Robust processes were not in place to monitor staffing. Systems for checking staff had completed care calls and had stayed the correct length of time were not in place. Rotas were produced informing staff of the care calls they were scheduled to complete. Paper copies of the rotas were collated from each staff member – these showed some staff marked these to demonstrate when they had completed a care call whilst other staff did not. This meant there was no reliable system to check if people had received their calls, or that calls were carried out at the time of their choosing. Agency staff did not receive an induction into the service. Checked records and found that whilst most agency staff had a profile in place there was no evidence they had been inducted into the service or introduced to the people they were supporting. This was of particular concern at night where agency were lone working 3-4 nights a week. There was no record of them being inducted into emergency procedures, on-call information or fire procedures. We discussed this with the regional team who informed us they would ensure agency staff were no longer lone working at night. Staff were not receiving supervisions to support them in their roles. Records of supervision were mainly over a year old. This meant staff had not had the opportunity to raise concerns, discuss their performance or receive support to develop their skills during this time. Staff had completed eLearning training although face to face training was overdue for some. Regional management team gave assurances this was being booked. This was a breach of Regulation 18 (Staffing) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and their relatives told us they felt the service was clean and well maintained. They confirmed staff wore personal protective equipment such as gloves and aprons when supporting people with their personal care. “They wear gloves when washing [name] and aprons.”

Staff confirmed they had access to personal protective equipment (PPE) as required and understood how this should be used safely. One staff member told us, “We all wear PPE and it’s always there for us. We have never had an issue with that.”

Staff had received training in safe infection prevention and control and were aware of their responsibilities in relation to this. Staff had access to PPE and there were sufficient stocks in place and accessible. Communal areas were cleaned to a good standard.

People did not always receive their medicines safely as effective systems were not in place in relation to ordering, administration and monitoring. One person staff ordered their medicines, but they did not always receive these on time. They told us, “I’m sometimes waiting for it because it’s not delivered. I don’t know where it goes wrong.” One relative told us they felt confident with regular staff supporting their loved one with medicines but not with agency staff as errors had been made. Another relative told us that although systems were generally okay, medicines such as anti-biotics were not always given at the correct intervals which may make them less effective.

Staff told us they were not confident people were receiving their medicines in line with their prescriptions. They expressed concern regarding how medicines were being ordered, how senior staff were recording and how agency were working. One staff member said, “It’s really quite difficult. We know the agency aren’t always getting things right but we just don’t always have the time to go and check and do their job as well. It needs to be better.” Another staff member told us, “We keep saying medication is running out. People have gone without meds.” Another staff member described how senior staff were not always paying attention to detail and they had concerns regarding how medicines forms were printed and signed off which they felt may result in errors occurring.

Robust medicines systems were not in place which meant people did not always receive their medicines in line with their prescriptions. There was no system in place for inducting and monitoring agency staff supporting people with their medicines. Incident forms detailed ten occasions when agency staff had either failed to administer people’s medicines or administered them incorrectly. Despite this, not additional checks or training had been implemented. Communication regarding changes to people’s medicines was not always effective. Changes to one person’s medicines had led to them receiving additional doses of medicine over a two month period with the risk this could have had a significant impact on their well-being. Systems for ordering and stock control were not effective. Where medicines were not on the regular schedule for re-ordering there was no process in place for monitoring people’s stock levels to ensure prescription requests were submitted in a timely way. This led to delays in people’s medicines being available to them.