London Care - Brighton

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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

We identified 3 breaches of legal regulation for safe care and treatment, safeguarding and staffing. People were not always protected from the risk of avoidable harm and abuse. Medicines were not always managed safely or administered as per prescriber instructions. Although staff had received safeguarding training, they did not always understand what abuse was, or their responsibility to report concerns. Leaders had not recognised, recorded or reported incidents to appropriate external agencies. This meant the provider could not demonstrate lessons learnt or how to reduce risks to people. Staff did not always have the skills or knowledge to provide safe care. The provider had a diverse staff team who did not always have care experience. People told us they did not always have regular staff supporting them. They felt staff did not always know them well enough to anticipate their needs. Some care calls were late, cut short and missed which resulted in rushed support being provided. This meant people were at risk of avoidable harm. Infection prevention protocols were not always followed by staff whilst providing care. People's care plans were not always person-centred nor reflective of their current support needs.

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.

People did not always know how to raise concerns. Feedback from people was mixed. Two people told us they have not needed to raise concerns. However, other people told us they had raised concerns, but nothing had changed. A relative said “I have left several messages for the manager and several emails, and I am still waiting for a response. I have asked for a meeting with the manager to discuss all my concerns.”

Staff did not always understand what incidents were. They told us about first aid and levels of medicine support people needed. Some staff told us learning was shared with them when things went wrong. One staff said, “Sometimes we go to a clients place and if we do something wrong, the manager tells us what we did wrong and how to put it right.” Leaders did not always recognise incidents when they had occurred or how to prevent them happening again. For example, they told us there had been no incidents. However, people told us they had reported incidents such as medicines errors, meal support incidents which could have resulted in fires, security issues such as front doors and key safes left unlocked or open, and staff “shouting” at them. These had not been documented. Trends or patterns had not been explored, and no clear lessons were learned. The registered manager told us they had learned lessons from working with the local authority to ensure better communication with them and people before taking on new packages of care.

The provider had policies with clear guidance and processes for staff. However, this was not always followed. Individual incidents were not documented or investigated, and the provider was not able to identify trends or patterns, nor any learned lessons from any repeat incidents. This placed people at risk of avoidable harm.

Some people received support from healthcare professionals in relation to specific health needs such as catheter care or diabetes. Care plans were not always completed with accurate or detailed information about these healthcare professionals and how the service worked with them to ensure continuity.

Some staff told us they had seen nurses during care calls. However, they could not explain how they worked in a joined-up approach to ensure continuity of people’s care. Most staff could not give clear examples of how well they knew a person and how to manage their risks safely.

Feedback from external agencies and professionals about staff working with them to promote good outcomes for people was mixed. One professional told us how they were regularly meeting with the provider to address concerns, how the provider had been engaged in this process and had attended regular meetings with them. Two other professionals told us about poor communication from the service in getting responses to their concerns.

We looked at 8 care plans and most contained details of people’s GPs. However, there was not always clear guidance for staff on what to do in an emergency and which relevant health professionals to contact, such as specific nurse teams for catheter care or management of diabetes.

People told us they did not always feel safe with staff in their homes. A relative told us, “There was one carer who was very abrupt and rude to both [person] and myself. I contacted the manager to ask for her not to be sent again and removed from [person’s] carers. She had left [person’s] front door open for all public to see which was very unsafe for them as they were not aware of it.” A person told us, “There is only 1 carer I feel safe with, and she comes in the morning 4 times a week, the rest I do not like in my home. They are surly, don't speak and not friendly.” People told us about incidents that had occurred in their homes they had reported to the office. They told us there had been little improvements to the service.

Some staff told us they had not received safeguarding training. Records showed staff had completed training in safeguarding. However, staff did not always understand what abuse was, or their responsibility to report concerns. One staff told us, “I remember more of the hands on bits - I know a little bit about confidentiality I don’t think my knowledge of safeguarding is good. If I had concerns, I would report to the office. I was told not to write in the notes but report it to the office.” The branch manager told us there had been no accidents, incidents or near misses. They said, “We haven't had any yet. So, I would personally go to [registered manager] and ask how we document this. Near misses, not had any of them. Again, I'd have to go back to [registered manager] and ask which part of the system do I go onto.” They had not identified incidents from concerns raised by people.

The provider had policies in safeguarding and accidents, incidents and near misses with guidance for staff and leaders. However, they did not always follow these. The registered manager told us there were no accidents, incidents, near misses or medicine errors. People told us about incidents which occurred. We reviewed records including medicines administration records and complaints. Safeguarding information was not always recognised from complaints or concerns raised by people. Incidents had occurred but had not been uploaded to the provider’s computerised system. There was no evidence incidents had been investigated, what actions were taken, or any learning identified. Safety events were not always reported to external agencies. There was a whistleblowing policy but not all staff knew what it was. One staff member told us they were shouted at by a leader and that they did not know they could report it.

People told us they were not always confident staff knew them well, nor what their needs or preferences were. They told us they had not had a review of their needs. Care plans did not always contain vital information about people. For example, one person told us they required moving and handling support. They said, “I always feel very sick and have vomited because of the way they put me in the sling and swing me about whilst I’m in the hoist. I have to take anti sickness tablets before they arrive.” We reviewed the person’s moving and handling risk assessment. Although the provider had updated the plan prior to sending it to us, it did not contain information about the persons motion sickness and how staff should support them.

Staff told us they had time to read people’s care plans but did not always know people well. Some staff were unable to tell us about people’s specific health conditions such as diabetes, catheter care, nutrition or moving and handling, and the risks associated with these. Staff were not aware of tools such as waterlow risk assessment (prevent pressure sores) and MUST (screening tool used to identify risks of malnutrition), and how these could be used to minimise risks.

People's records did not always identify or assess risks. For people that had specific health conditions, there was limited information about how this impacted on their lives, how staff should support or what to do if they had concerns.

Feedback from people was mixed. Some people told us that staff made sure their homes were clean and tidy. However, other people told us staff did not always empty or clean equipment such as commodes and bins. A person said, “They (staff) can’t even wash up properly.” They explained how they felt frustrated when staff did not know how to do tasks.

Staff told us there were tasks in people’s care plans which told them if they needed to complete any domestic tasks, including emptying commodes or waste bins. One staff said, “We clean the kitchen, empty bins, any dangerous objects we take away and make the home comfortable for the person.” Leaders addressed in a team meeting they had received complaints that not all cleaning tasks were being completed. However, where people had raised concerns, this had not been addressed with specific staff involved.

Some care plans had environmental risk assessments and fire evacuation plans. However, not all were detailed or personalised to each individual. For example, some did not contain specific information on where gas, electric or water supplies were, potential trip hazards or details of what was the quickest or safest route for that person to exit their home in an emergency.

People and their relatives told us their care calls were late, cut short or missed. They told us they were not always informed by the office if staff were running late. One person said, “I would say that carers are late every day since I have had carers which is 6 months. It’s because they don’t drive or have access to cars.” People told us they did not get a rota which would tell them the time of their calls, or which staff would be supporting them. They told us they did not always get regular staff, and that they were not always skilled and trained. Comments included, “I have had this service for 3 months and have on average 21 different carers walking through my house a week. I never know who is coming during the day or week. There are no rotas”, “Definitely not trained, knowledgeable or professional” and “My [person] gets at least 10 different sets of carers per week. That’s about 20 plus different people visiting them which is very disconcerting and confusing for them.”

Staff told us they did not always have enough travel time for calls. They said they did not drive and had to use public transport to get to people’s homes. This meant they were late for some calls and had to cut others short. The branch manager told us people did not receive rotas for their calls. They said, “No, but there is a way for them [people] to be able to see the rota and care notes, it's just difficult to do it with IT. So, we don't tend to do it. Most care calls are within half an hour of the time.” Staff did not always have the skills or knowledge to provide safe care. Not all staff had prior care experience and the knowledge or skills to support people safely. Staff told us they had not received training in safeguarding and mental capacity. However, training records showed they had completed their online training. Staff were not confident or knowledgeable to identify incidents and did not always get consent before completing care tasks. Staff had received training in moving and handling. However, no competencies had been completed to ensure staff were suitably skilled to deliver care safely. Where concerns about staff conduct and skills were raised, the provider could not evidence this was effectively addressed with individual staff nor retraining or coaching offered. For example, one staff had performed moving and handling tasks on their own. Although leaders spoke about it in a supervision, the staff member was not offered retraining or coaching, and no additional spot checks had taken place. This meant people were at risk of avoidable harm.

Systems were not always effective to ensure people received care when they needed it. The provider had not effectively monitored electronic data for care call times to identify the concerns found during the assessment. People were at risk of avoidable harm due to staff being late and rushing support. People did not always have the same staff involved in their care. The branch manager said, “So that is a work in progress at the moment. Have templated and rota'd for the next 2 weeks. As much as clients like to have the same carers every day, we can’t. We do try to do 4 days of the same carers but 3 days with another carer, if possible, in case staff become complacent.” This meant staff did not always get to know people well and how to best to support them. The provider had policies and processes in place to manage staffing. However, this was not effective. Staff did not demonstrate a good understanding of their roles and how to keep people safe. One staff said, “Induction was alright. We were taught how to do some things and shadowing cemented that. I thought there would be more training especially as they knew I hadn't worked in care before. I thought there would be more than 2 days of shadowing.” The registered manager told us they had recognised some staff required additional training and support. During the assessment, leaders held a quiz with staff to develop their knowledge of basic food items and how to support people with meals. However, where concerns had been raised about the conduct and capability of staff, this was not addressed in supervisions and no additional training or coaching had been offered. There had been no competencies or performance management to ensure staff had the right knowledge and skills to support people safely. The provider had a safe recruitment process in place.

Not all people felt safe from the risk of infection. Feedback from people was mixed about whether staff used personal protective equipment (PPE). One relative said, “There are pots for medicines so staff can be prepared, but they then put the tablets into their hands instead of in the pots. I’ve got gloves here and some of them come with gloves, but some staff don’t use gloves. They just put it onto their hands, and they’ve been on buses, they don’t wash their hands.” Some people told us their homes were not left clean or tidy, that waste bins had not been emptied nor commodes cleaned.

Staff told us they had training in infection control. Staff told us how they use PPE. One staff said, “We have gloves, apron, everything. I use them, and my mask if I need to. At every visit I use my gloves, if I do personal care I put on my apron. Always with my gloves, administer medication, after doing personal care I remove gloves and put new ones on.” However, people and relatives confirmed this was not the case across the whole staff team.

The provider had a policy for infection control. PPE was available for staff to collect from the office. The provider had undertaken spot checks on staff working in people’s homes. However, where concerns were noted around infection prevention and control (IPC), it had not been addressed with staff.

People did not always receive their medicines as prescribed or in line with current legislation. A relative said, “My wife has been given 4 paracetamols within 4 hours. Carers lack any knowledge of my wife’s needs or training it appears. They sign their app to say they have given my wife her medication, but this cannot be verified by us as we never see it.” Another relative told us “I have phoned the manager when carers do not turn up or [their] medication has not been given and tablets found on the floor. One medicine went missing, and we have never found it. Plus, [their] medication has been placed in different boxes so there is a risk of carers giving [person] the wrong medication at the wrong time of day. When I have spoken to the manager, she just says she will look into it and never gets back to me, and we don’t really see any improvement.”

Staff told us they had received medicines training. However regular spot checks, supervision and competencies to check their knowledge and understanding had not been completed. Staff did not always demonstrate knowledge of good medicine practice and what to do in the event of a medicines error.

Medicines were not always managed safely and in line with the provider’s medication policy. The provider had not ensured that medicine administration records (MARs) had been audited. Where people had reported errors, these were not recorded as incidents. It was not clear what actions had been taken to ensure people were not harmed and lessons learnt to prevent it happening again. For example, the branch manager had responded to a relative’s complaint informing them of actions they would take. One action included having reactive supervisions with 6 staff about poor medicine management and ineffective support. However, when we reviewed records, leaders had not addressed the issues. The provider was not able to evidence any follow up actions to prevent further risks of avoidable harm, including checking if staff were competent to administer medicines safely or to demonstrate any lessons learnt. One person had controlled drugs. Their medicine was not monitored weekly as per the provider’s medication policy.