HF Trust Cheshire

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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

The provider had not ensured there was an effective system in place to ensure people’s risks were managed effectively. Care and risk management plans were not always put in place to mitigate these risks and to ensure they received the required care and support. Provider oversight was not effective with safeguarding process within services. Safeguarding incidents and concerns had gone unreported. There were missed opportunities for lessons to be learnt. The provider had not ensured effective oversight and management of medicines. We identified a breach of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) as people in some of the services were under constant supervision and did not have a DoLS authorisation in place. In one instance a Court of Protection DoLS had expired. There was a significant use of agency staff due to the lack of permanent staff, although, wherever possible, the same agency staff were used. We found low staff training compliance in key mandatory training and risk-based topics. Staff competencies were not checked for moving and handling of people in between their allocated 3 yearly practical course.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We had a mixed response from people's relatives. Some relatives felt if they had any concerns or complaints they would be listened to and had been listened to in the past. However, in most cases, relatives did not know who to approach if they had any concerns and this gave them no confidence that they would be listened to. In one address, relatives said they did not know who the service manager was and could not get hold of staff.

Staff members told us incidents had occurred with debriefing sessions not completed and no inclusion in team meetings. Staff members told us they had tried to raise quality concerns prior to the recent new management team being in post and concerns had not been listened to, not acted upon or dismissed. Staff told us that they held debriefs after incidents with the people they support but this was not replicated by management with staff as required. Leaders told us, ‘’Incidents and accidents trends were reported monthly and analysed at a regional level by the manager. This was a standard item on the team meeting agenda’s where learning from incidents was discussed. Where incidents related to a serious safeguarding, actions were implemented within the service and these are then discussed in supervisions as a standard awareness of lessons learned. We then use incidents as scenarios to promote understanding and introduce best practice. The senior health and safety team also monitor and check actions and learning to help support safer practice across the services’’. They further told us, ‘’We hold debriefs; we have examples of where we needed to learn as an organisation and as such the learning was shared and discussion held in every team meeting where required and we identify local policy changes and adopt learning from this.''

Incidents and accidents were not previously always investigated or reported appropriately. The provider had recognised this and reflected it in their own quality assurance framework. A specific action plan was being worked through. There have been missed opportunities for lessons to be learned and shared learning, including debriefing appropriately with staff after accidents/incidents or safeguarding matters. Monthly analysis of accidents and incidents had not always been taking place, this was also corroborated by the lack of senior or operations manager audits not being completed monthly from January to August 2024.

Feedback was mixed from family members, one family member told us, ''They are much happier with the care and support [person] receives from HFT than with the previous provider.'' Another family member told us when their family member moved into one of the services, they were actively involved in the care planning process at the start but have not been recently involved in care plan reviews and meetings much since. Another family member told us their loved one moved between services at HFT and said, ‘’This was rushed, the bungalow was not ready, the previous residents' belongings needed to be moved, and it needed new kitchen equipment which I purchased.'' Another family member shared that, ‘’[Person] moved into HFT [date] this was a positive time for us as needs were considered and a solid and effective plan was put into place, this wouldn't happen if we were in the same situation now.''

Leaders told us, ‘’Ongoing care plan reviews are held with the people we support and their representatives. We look to fully advocate people where we recognise we are not the right support provider and create a clear pathway of support with the decisions and choices being person centred and accessing services they need. People that transition into service are liaised with social workers, advocates, self-funders and we organise planning meetings assessing the level of support to ensure HFT is the right provider. We work with new providers to smoothly transition people out, have a staged approach and planned with person at the centre of this. We use the Person Centred Advocacy and Support model to provide the right amount of support to people and promoting people's independence. We liaise with a range of medical and social care professionals to have a clear and supported plan for people we support and share relevant information to enable service users live fulfilled lives that they are at the heart in making those decisions or supported to make those decisions’’.

Partners we spoke with raised concerns regarding safe systems, pathways and transitions. Partners told us information relating to people’s care needs was not always provided when people moved between services. When partners requested care records, the provider was not always forthcoming with providing this information.

Care plans were not always written with people. There was an absence of a reviewing process of care and support in transition to HFT and the subsequent frequency of care plan reviews. We did not see care plans written, where applicable, with professional input, for example, an epilepsy nurse or physiotherapists.

The feedback we received was mixed. Family members told us, ‘’My family member is physically and emotionally safe in the care of the service’’. Another person told us, ‘’[Person] is safe in the hands of HFT and have no concerns’’. Another family member told us, ‘’Staff do their best to keep [Person] safe but there isn't enough staff to do this’’. Another family member stated the main problem was low staffing levels and high staff turnaround. We heard from a family member who said, ‘’[Person] often telephones in a distressed state due to their concerns about not knowing the staff who will be waking them up in the morning.'' Feedback from a family member stated, ‘’There was recently a new member of staff who started who was dismissed very quickly after a safeguarding incident, perhaps the safeguarding training needs looking at.'' Another family member shared, ‘’There is a negative atmosphere in [Persons] home at the moment and staff are using 'one-up' approach towards each other and have involved [person] in this’’, staff saying, ‘’You like me the best [person] don't you’’. This is unpleasant for [Persons] staff who are ‘telling tales’ on each other and there is one member of staff who uses sarcasm with [person], this is disrespectful and inappropriate.''

Staff told us that they had been reporting neglect of a person for some time by staff and had been ignored by senior leaders, a new service manager started and the matter was addressed. Staff shared they had tried to raise matters in the past and recently with management, but matters had not been addressed, this was due to the pace of changing management, it has been an unsettled period for staff. Leaders told us, ‘’Staff are inducted with a 12-week training plan, this includes reading and understanding our whistle-blowing and safeguarding policy and is backed up by training required to be undertake with a competency assessment. Staff undertake supported supervision where safeguarding is discussed, tested, and understood, and opportunity to raise any concerns in a safe environment. Staff can email an inbox or leave a voicemail anonymously. Whistle-blowing posters are in staff 'sleep in' rooms. Safeguarding issues are investigated by the local manager in the first instance and is reported back to senior managers. Where the issue is more serious and impartial manager from a different part of HFT is brought in to investigate. The most serious incidents will be supported by a response team and 72-hour report and meeting lead by the head of care and support and the safeguarding lead. Safeguarding incidents are discussed at team meetings and in supervision. Learning is shared across the local region and wider where organisational learning in needed. This then influences policy and procedure.''

The provider had not ensured that incidents, accidents and safeguarding referrals had been appropriately identified by staff, reported and actioned. There has been a lack of oversight and governance including reporting by staff as required. DoLS (Deprivation of Liberty Safeguards) have not been applied for people who have their liberty deprived. Restrictions have not been considered and capacity assessments have not been completed, in some instances, to also include best interest decisions processes. We also observed capacity assessments and best interest decision making were out of date for people. We observed a Court of Protection DoLS that was dated from 2019, this should have been reviewed and reapplied annually and the supporting information and capacity assessment was not available. People were being inappropriately deprived of their liberty and without lawful authorisation. We were told by the senior management on our first office visit that analysis of accidents and incidents will be implemented moving forward. The Local Authority also identified as part of their quality monitoring processes that there had been safeguarding incidents which had not been reported to them and subsequently, we were not notified. The provider did not have a DoLS and a safeguarding log to have effective oversight of the services. We observed unsafe practice of a loaded shopping trolley being brought home from the supermarket in the back of a mobility vehicle while carrying people in receipt of support, this practice was removed from the service once it was reported by the inspector to the turn around manager in post at the time of assessment.

There was mixed feedback from family members. Some told us the care provided supported and enabled people to do the things that mattered to them. Some family members shared concerns on kitchen activity not being risk assessed appropriately and, ‘’[Person] moved into the service [date] and at the time there was a strong manager and team of staff in place who worked with [Person] and family to design a care and support plan. This has since changed and is no longer the case.'' Family members were not always involved in creating or reviewing the positive behavioural support Plans, one family member told us, ‘’There was a behaviour support plan, but it has not been updated. Alternative seating suggested by the occupational therapist is no good. I have asked for a reassessment.''

Staff have told us they have received training on Assessnet (an assessment system) but didn't feel confident using it, some staff reported that it is not used by some staff members, some managers told us they were not fully aware of how to utilise the system to its full potential and felt they needed more training. Leaders told us, ‘’We use a central system called Assessnet, staff are aware that incident reporting is utilised on this system for investigation, there are local, regional, and organisational risk registers that are completed and discussed in team meetings, operational meetings for action plans to be implemented and mitigate risk. Positive risk taking doesn’t override safety but is actively encouraged where possible via best interest meetings, person centred planning (PCP) and involved all people in a service users care and support provision. This is also reviewed to ensure there is the least restrictive support in place at all times. We also support the mental capacity act and key decision making including supporting people where poor decisions may have occurred to ensure safety and appropriate decisions are being fully supported.''

Care and support plans were not always created and written concurrently with accompanying risk assessments. Information held in care plans was not transferred to risks assessments and subsequently the risks were not mitigated. One person used several pieces of equipment, these were reflected in part in their care plan but not in their risk assessments. We observed choking risk assessments out of date and evacuation plans not considering the support required at night. One person was supported with high risks around behaviours that presented with challenges. Information held in their risk assessment was not in place such as the location of ligature cutters and the door sensors described in the risk assessment were not active and not in use in the service. One person was at risk of skin pressure damage. This was not reflected in their care plan and pressure relief monitoring and preventative care was not considered. One person was recently admitted and later discharged from hospital from sepsis. This information was not reflected in a care plan or a risk assessment to consider preventative care and support. One person had a diagnosis of epilepsy. There was no monitoring and recording sheets available at the time in the service. A recent liaison with the GP had concluded a person may have experienced a seizure yet this was not recorded appropriately for monitoring purposes. Health appointments feedback and outcomes for people were not always completed effectively and this did not support staff to support appropriately and effectively. People did not always have specific care details around the support they would need with a health diagnosis, for example, one person's care plan did not reflect the care and support they required with their Parkinson's diagnosis.

Family members had no concerns about the environment their loved ones lived in. We observed a person using a vinyl chair. The footrest was broken, and their head tilted forward which was unsupported with their chin resting on their chest. Their feet were also left unsupported. Staff had not considered liaising with professionals for equipment such as a pillow or a repositioning alternative for their feet in the interim while the chair was waiting to be fixed. We found a number of the homes' bedrooms, or parts of communal areas, such as lounges being used as staff offices. This impacted on the space people had in their own homes. This was largely due to the storage of paperwork and items for staff. This was not following the Real Tenancy Test with regards to people having control of what happens in their own home. In one home we found the bathroom was in urgent need of repairs or upgrading. The linoleum on the floor had staining that staff reported came from bodily fluids and had been there for over 12 months. Staff told us they had reported this issue several times over the past year, and nothing had changed.

One staff member told us of a service they worked in and felt, ‘’The environment did not meet the needs of people, one person has needed a wet room for a long time and this is still outstanding, the service needs decorating and brightening up as it is dull, none of the bedrooms have been properly decorated since they moved in.'' Leaders told us, ‘’We have health and safety team that review properties inline with key safety concerns (Fire, Electrical, Security etc.) we have on site weekly audits completed by support staff, monthly audits completed by deputy service managers / team leaders, Monthly Audits Completed by the service manager, and monthly audit completed by the regional managers this overlaps levels of safety and action plans are produced via these plans to refer on planned works to housing services, contractors etc. Any concerns are addressed and planned and tracked via our central services teams and communicated out to the region. Our Health and safety lead also completes regular audit as part of a full check on all properties".

There was a health and safety policy to guide staff in how to keep people safe. Weekly health and safety checks were undertaken, and where issues were identified, these were rectified. The management team had oversight over the health and safety checks at the services. The regional audits through service visits were not being completed by management from January to August 2024. There were processes in place to ensure fire safety was well managed. However, people's emergency evacuation plans did not always guide staff in how to support to evacuate safely.

Relatives told us, "Some staff are excellent, however, they are always short staffed, and [Person] does not get their 1:1 hours.'' "Shifts are cancelled”, “The speech and language therapist suggested a special iPad for [Person]. It is not used much as the staff are not trained enough", "I have given healthy option ideas [nutrition] but change of staff means no consistency", "I would like better communication”, "Staff seem to change a lot", "Newer staff are not so good at deflecting stress", and "Staff are not trained". Family members shared they are brought in to provide cover and activity as there were shortages of staff. People told us, ‘’Staff could benefit from more training around safe moving and handling and dealing with challenging behaviours.'' Another person told us, ‘’Staff do their very best to care for [Person], however low staffing levels made this more difficult for them, there isn't continuity of care for [Person]. Due to the high staff turnover and some staff not gelling with [Person], their behaviour is often described as aggressive. However this is likely a result of feeling disappointed at the many cancellations and being nervous when they didn't know the staff who were supporting them. It is difficult for [Person] to form long-term relationships with staff as there is so much change and moving around.'' One family member shared that they are kept updated of [Persons] care and support needs, however, they mentioned failings around communication in this regard and within the home itself, miscommunication was a common problem.'' Another family member said, ‘’There have been many recent staff changes but feel that visiting once a week helps. I used to know all the staffs names but now this isn't the case.''

Staff feedback highlight staff were moved around to cover services and activities were not happening for people requiring one to one support at times due to staff shortages and staff covering for other services. The recruitment of staff legally able to drive into teams was poor and sometimes due to not having drivers on duty people had missed out on activities, visiting families or having to stay in due to staff shortages. Feedback from leader’s stated, ‘’We currently have 10 support worker vacancies as we have 7 in pre-employment, this will reduce the number down to 3 support worker vacancies if all pass checks. one service manager is in pre-employment, we also have 3 team leader posts going through vetting and interview process with recruitment.'' They further told us, ‘’Staff go through a robust recruitment process in line with policy, any specific vacancy requirements are discussed with the recruitment manager in a weekly action plan meeting and advertised accordingly. Staff are competency observed in their work in key areas of support such as supporting people with eating and drinking and taking medication. This works alongside a range of e-learning and face to face required training for the region that is checked monthly and reported on to ensure accurate and best practice training is in date.''

People were not always receiving their funded 1:1 hours due to staffing shortages. The provider was in the process of a recruitment campaign. Staff training compliance was low in a number of key mandatory subjects, the provider did not have the appropriate training subjects available for staff such as Makaton, ligature removal and PBM. This PBM training is to compliment the positive behavioural support plans, for staff to be trained when they are required to undertake breakaway techniques or restrain someone appropriately and safely or move someone to safety. We found staff did not receive regular supervisions or annual appraisals. Staff competency checks were not being undertaken for moving and handling of people in between their three yearly training sessions.

Family members told us, ‘’The home is clean and well maintained. [Person] is always physically clean and healthy looking, they take good care of her skin especially.'' Another person stated, ‘’They are supported to live in a safe environment, any concerns or hazards are acted upon in a timely manner, we have no concerns.’’ In some services there were rips in the furniture, a persons own vinyl chair and dining room chairs were worn and ripped. We observed a vinyl floor in one toilet was heavily stained with bodily fluid, flooring which needs to be replaced. We observed staff using personal protective equipment appropriately.

Leaders told us, ‘’ Weekly service checks are done on the 'assessnet system' by support workers and overlapping monthly audits by the deputy service managers / team leaders, and service managers to ensure a clean environment is in place for the people we support with cleaning rotas part of this process. Any works that are of a larger health concern would be reported to the health and safety team for immediate remedy. Processes are in place such as utilising personal protective equipment, cleaning rotas, employing professional cleaners, conducting risk assessments, and practising separate washing of clothes in service with multiple occupants.''

The provider had a robust Infection control policy and procedure, we observed on the electronic system deputy managers and team leaders were part of the auditing processes, what we did observe was the senior leadership had not had ineffective oversight and had not always been undertaking service visits as part of the governance processes from January to August 2024.

Relatives told us, ‘’The lines of communication are variable and currently poor’’. They gave an example of [Person] being given a lot of medication, however, staff were not able to explain it was all for. We observed a person being supported to take their medication, they were taken to a quiet place away from the table, the staff member was talking with the person through the process.

Staff feed back they undertake e-learning training and had their competencies assessed. This was reassessed annually or sooner if there has been a medication error. Leaders told us, ‘’The support team complete a weekly audit and undertake temperature checks on the medication cabinets and weekly stock control. Managers complete a weekly check, for example checking for dates and that medication records are signed. The service managers have a monthly medication themed audit with actions set to improve safer medication practice. Each person has ‘my medication guide’, a risk assessment, medication guidelines such as minimum temperature medication can be at agreed ranges. There is a local policy for controlled drugs and an organisational policy and procedure for medication and all staff members sign off key policies and risk assessments.''

Topical medication administration records were not always in place for staff to record the use of creams. We observed two people that use flammable creams which staff apply. The flammability was not reflected in a risk assessment for one person and not reflected in a care plan for another person. MAR (medication administration records) transcribing was incomplete for one person with no clear instruction of how staff were to administer medicines. Medication was not signed or double signed appropriately and not stock checked. Opening labels on creams and bottles of medicated products was ineffective or not in practice. This put people at risk of using creams that were out of date or passed the manufactured instructions. Medication equipment being used was not being washed such as inhaler spacers which had a thick white substance coated in ones observed, mouth pieces and face masks that were used with the spacers were visibly dirty. The weekly audits that were being completed were not fully effective as these issues were not identified. In one service, the weekly medication audits were not being completed. We observed capacity assessments for medication to be out of date. When required medication did not always have protocols in place to support staff to administer effectively and in a person-centred way. Staff training for medication showed 82% of staff had been assigned this training. The medication in community settings policy and procedure showed 49% of staff had been assigned this training.