Fosse Healthcare - Nottinghamshire

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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

During our assessment, we have identified breaches in relation to staffing. We assessed all 8 quality statements in the safe key question and found areas of good practice and concern. Though the assessment of these areas indicated areas of good practice since the last inspection, our rating for the key question remains requires improvement. A sudden recent reduction in staff numbers had resulted in an increase in late calls and expectations on staff to complete more call. People have felt their concerns about this were not being listened to. People and those important to them were supported to raise concerns when they didn’t feel safe. However, people and relatives did not always feel concerns would be acted on. When concerns had been raised, managers reported these to the relevant agencies and action was taken to safeguard people from further risk. There have been occasions when the provider was asked by the local authority safeguarding to make improvements. Staff assessed and reviewed safety risks to people and made sure people, and those important to them participated in making decisions about how they wished to be supported to stay safe. Staff received relevant training to meet the range of people’s needs at the service. Staff received support through supervision and appraisal to support their continuous learning and improve their working practice. Managers checked the suitability of staff to ensure they were suitable and fit to provide care. People’s medicines were managed well; however, there were occasions when time critical calls were between 30-60 minutes later than planned, which could impact people’s health and safety. Staff understood how to reduce the risk of the spread of infection. We have asked the provider for an action plan in response to our concerns.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us that they had regular reflective supervision sessions to review what was working well, and what could be improved at the service. However, out of the 47 staff who responded to our questionnaire, many felt that their views were not valued. Many staff felt able and understood the process to report concerns to the office-based staff and management. However, the majority of the 47 staff we spoke with did not always feel that the concerns would be acted on, or, if they were acted on, they were not informed of the outcome.

The majority of people and relatives did not always feel able to speak up if they had a concern. Some told us that when they had raised an issue about their care, they did not always feel action would be taken. Some told us they had stopped raising concerns with office-based staff as they rarely or never got a call back about the issues they had raised. One person told us about an issue they had raised and their experience of reporting it to the office-based staff. “I have heard nothing since. I have even put it in an email, but absolutely ignored.” A relative said, “You only get heard by them after repeated interventions. The stress levels are causing problems. It’s ridiculous. Nobody wants to be accountable.” It was noted that some people did speak positively about the approach of office-based staff and did feel concerns were acted on.

There were processes to review incidents and then make improvements. Staff were provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. Staff meetings allowed staff to reflect on what was working well, and what could be improved at the service. There was a policy on the duty of candour. This policy guided staff to tell the person (or, where appropriate their advocate) when something had gone wrong. We reviewed complaints that had been made and saw this policy had been followed. However, following the feedback received from people, relatives, and staff, it was evident that the processes were not always effective.

The provider has a contract with the local authority which sees people referred to them to receive care within their own homes. The local authority suspended this contract due to concerns about the service provided. The local authority have told us they are meeting with the provider to discuss their plans for improvement. It should be noted that during the inspection the provider has disputed some of the concerns raised by the local authority. A healthcare professional, involved with the transferring people from hospital to home care said, “I have found that the Fosse coordinators in the office to be very professional and helpful and showed a good understanding about the needs of the people they are supporting. The only occasional really negative feed-back I have had from clients and their families has been about the carers rushing their tasks and the late arrival of the carers.” Another healthcare professional said, “Those staff who I have met with appeared keen to engage and learn and do the best for those receiving care. For example, asking about referrals to other agencies, about pieces of equipment and about access to the community. They just need to be a little more proactive and flexible in their approach.” A third healthcare professional told us that whilst they have found staff to helpful “helpful” and “polite.” They have had concerns reported to them about staff arrival times for calls.

Staff kept clear summary documentation on people’s holistic needs. If the person required a hospital admission, this document could go with them to the hospital. This meant hospital staff would have clear guidance on how the person liked to be supported. Where people required external health and social care support, documentation showed that suitable referrals had been made. For example, referrals to occupational therapists had been made.

People told us that staff supported them with health and social care appointments when required. Some people told us staff helped them to attend appointments with their GP. Staff had good knowledge of which health and social care professionals supported which people. Staff knew how to monitor people’s health conditions, to ensure timely referrals were made to other services. For example, should a person be due a visit to their GP or dentist. A health care professional, involved with transferring people from hospital to home care said, “I have found the Fosse coordinators in the office to be very professional and helpful and showed a good understanding about the needs of the people they are supporting. The only occasional really negative feed-back I have had from clients and their families has been about the carers rushing their tasks and the late arrival of the carers.”

Staff understood how to respond to allegations of abuse. Staff told us issues about people’s safety were, overall, managed well by the management team. Staff were confident in using whistleblowing processes if they felt concerns were not being responded to. The registered manager understood how to respond to allegations of abuse. They had a clear process of how to investigate and keep people safe. Staff knew where to find the safeguarding policy. They were aware of the policy guidance and knew how to follow it to keep people safe from potential abuse.

If an allegation of abuse was made, there were appropriate policies in place to guide the staff team. Records showed that incidents were quickly investigated and referred to the local authority safeguarding team if needed. We did note that there had been some safeguarding concerns upheld by the local authority team. This meant they had concluded that people had not always received the appropriate care as required. The provider had taken action to address this. People were kept safe when they went into the community. Care plans guided staff on how to keep people safe.

Most people and relatives told us they or their family members felt safe from abuse when staff provided care in their home. One person said “I wouldn’t be safe without their [staff] help. I just couldn’t do it without them.” A relative said, “[My family member} is happy with the care they receive and feels safe.” However, some had raised concerns that male care staff had been sent to their homes when requests had been made not to do so. Although no-one reported that anything untoward had occurred, this had made some feel uneasy and that their requests were not being listened to. People told us that there were no unlawful restrictions imposed on them. They were free to complete their own routines and live their lives as they wished.

People’s needs were clearly documented in their care plans, so staff had clear guidance on a person’s mental, physical, and social needs. Staff knew how to support people to manage risk. For example, care records contained guidance for staff on how to support people with their meals, the level of their independence and their ability to make decisions for themselves. Where incidents had occurred, there were opportunities for staff and people to review what had happened and ensure measures were put in place to prevent re-occurrence. Improved communication with people, relatives and staff were required to ensure people felt fully involved and valued with this process. Staff kept clear records on how they had supported people and at what time. This allowed changes in a person’s needs to be identified and improvements made to their planned care. There were clear processes in place for how to respond to an emergency. Staff had clear processes to follow to ensure people were safe in an emergency. These processes took into account people’s individual needs such as their mobility and mental health. This helped to keep people safe. Staff had received training on how to support people’s individual needs. Some people at the service could become distressed due to their mental health diagnosis. Staff had received training on how to support people when they became agitated. People’s communication needs were clearly recorded. This allowed staff to understand people’s needs/ wishes and support them to stay safe.

People told us that they were able to communicate their needs, to receive the right type of support. People had felt involved with the process of setting up their care plans, they discussed their care needs and overall, most people and relatives felt they or their relatives received the care they needed. People and relatives praised the approach of care staff. They felt they understood how to provide care in a safe way and understood how to reduce the risks to their or their family member’s safety. One person described how they needed to use their wheelchair to move around their home and staff understood how to support them with this safely. Some people and relatives did raise a concern about the consistency of the staff who attended the calls. Many stated when they had the same staff, they felt more assured as they understood what care was needed. Some raised frustration when inexperienced staff were sent, and they did not have an understanding of the care that was needed. However, the majority of people and relatives felt staff did understand the risks to their or their family member’s health and safety and appropriate care was provided.

Many of the staff we spoke with felt they were not always able to provide the care that was required at each call. Many commented on the number of calls they had to complete each day put them under pressure at some calls and some staff felt they were only able to provide basic levels of care to ensure people were safe. Staff told us they had access to people’s care records via an app which they could access on their work phone. Most told us this provided them with the information needed to provide safe care and to be aware of the risks to people’s safety. The registered manager felt people and relatives were given sufficient opportunity to discuss their care needs and risks to their health and safety.

People’s home environment was kept safe, by regular checks and review of appropriate risk assessments. Processes were in place for making people safe during an emergency. Guidance was provided for staff to follow. This guidance was amended as people’s circumstances changed to ensure it remained safe and effective.

People and relatives felt staff helped them to maintain a safe home environment.

Staff knew how to monitor the safety of the people’s homes. They were aware of how and who to report any concerns. This included reporting any fire hazards if people had begun to be unable to maintain their own home environment safely. The provider ensured staff knew how to respond in the event of an emergency evacuation. For example, if there was a fire and how to make people safe.

Most of the people and relatives we spoke with raised concerns about staffing; specifically relating to their call times, consistency of staff and the length of time staff stayed at each call. People told us staff were well trained and knew how to meet their needs. One person said, “Sometimes they run over on previous calls, but I am not told. They just turn up. “I did tell them that I only wanted females, but they have tried to send men 4 or 5 times now.” A second person said, “When we took them on, we asked for a time with the usual proviso of 30 mins either way. To be honest, they have never achieved that.” A third person said, “We don’t get a call if they are running late, it’s up to me to call the office to chase them. They just tell me they will look into it and call me back, but never do.” A relative said, “I would say they get 70% of their calls within the range stated, but evenings and weekends can be very hit and miss. We have had a 3-hour difference and then we had to rearrange rest of the day’s calls.”

We asked the provider to produce a report which analysed the arrival times of the staff for the three months prior to the inspection. The report showed that between 1 January 2024 and 1 April 2024 between 15-20% of calls were at least 30 minutes late with a small percentage of calls, 1-3% being over 120 minutes late. The provider was aware of these issues and had put systems in place to try to reduce this. Records showed between 1 April 2024 and 22 April 2024 punctuality of staff had improved from 17% to 12% of calls being 30+ minutes late. This showed signs that the new systems in place were beginning to be effective and would improve the experiences of people and the staff who cared for them. Staff had received training the provider had deemed required for their role. Most training for staff was up to date. Once staff were trained, there was a process to assess their competency. If needed, further support and training was then given to improve staff skills. Staff had also received training to be able to support with a learning disability. If staff were not providing the expected level of care, there were clear processes to monitor and improve their performance. Safe recruitment processes were followed. For example, previous employers were contacted to give references on the staff member. Staff had also had regular Disclosure and Barring Service (DBS) checks. These check the police database for convictions or warnings that may impact the staff members safety to work with people.

Almost all of the 47 staff we spoke with raised concerns with us about the number of calls they were expected to complete, the time assigned to each call and the lack of sufficient travel time to get to each call. They also felt this had impacted their ability to do their job well. One staff member said, “The rotas are full to beyond capacity for carers to do their job leading to service users getting calls that are late.” Another staff member said, “There is always enough time on calls because extra calls are slotted in where there is a gap and staff feel as though they have to rush.” A third staff member said, “We get five minutes to get to each call which can sometimes not be enough if there are road works or traffic. This leads to running late for calls.” The registered manager and other members of senior management acknowledged there had been recent issues with staffing numbers, primarily facing the loss of 3 care coordinators who plan the care staff’s calls. They told us they had recruited 3 new care coordinators, and this would help with a more efficient and productive way of managing staff rotas. They told us there was continued recruitment of more care staff taking place with a number of new staff due to start their roles soon. The registered manager and nominated individual were confident that the recruitment of unfamiliar staff would help ease the pressures on staff and see a reduction in late calls and improve people’s experiences.

People told us staff supported them to keep their homes clean. Most told us that staff wore personal protective equipment (PPE) when providing personal care in their homes. One person said, “All my carers wear full PPE and are forever changing their gloves.” Another person said, “They wear all the proper PPE too, so I feel comfortable with them.”

Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment, in a safe way. This protected people from the spread of infection. The registered manager was confident staff understood how to provide care in a way that reduce the risk of the spread of infection.

There were clear processes and policies, to ensure people’s home environment was kept clean and hygienic. This protected people from the spread of infection. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak. Infection control spot checks were completed to ensure staff continued to provide care in a way that reduced the risk of the spread of infection.

Some people and relatives told us they or their family members received the support they needed with their prescribed medicines. Most said staff understood what medicines were to be given, when they were to be given and how to do so safely. However, some said they have had issues when their calls have been later than expected and they have had their medicines given at later time than they wished. A relative said, “The carers do administer meds from the blister packs, and we haven’t had any problems – except when they are very late (to attend the call).” Another relative said, “The late calls do cause issues with giving medication as it throws the time out.” The relative told us some of the medicines were stated as being needed before meals or 12 hours between doses and on occasions this was not met due to calls being late.

Staff completed electronic medicine records which they updated at each call when they had administered a medicine. This updated each person’s care records immediately. When a staff member logged out of attending a person’s call if they had not completed all tasks related to that person’s medicines then an alert was sent to the office. The staff were then informed that an error or omission may have been made and they could go back to rectify the error. This reduced the risk of poor medicine management and the impact on people’s health and safety. Staff had received training on how to administer medicines safely. The management team had regularly assessed the staff’s competency, to ensure they were following best practice. We asked the provider to produce a report that showed how many ‘time critical’ calls (calls that needed to be completed on time due to specific medicines being needed) were late. From 29 January 2024 until 4 March 2024 approximately 3% of these calls were conducted between 30 and 60 minutes late. During the four-week period of staffing issues as described in this report, this increased to 6% and peaked at 9%. The two weeks prior to this inspection had seen this reduce down between 4% and 5%. This report showed that although the majority of people received their time critical medicines at the time they needed them. There have been periods of time when people did not get their medicines on time, which could place their health and safety at risk.

Staff were able to explain how they supported people to take their medicines safely. Staff told us they had the required information needed to know what medicines to give, the correct dosage and how to record when it had been taken. Staff knew who to report medicine concerns to. For example, if they felt a person’s medicine was no longer effective, they understood where to document this, and which health professionals to contact. The registered manager told us they felt people’s medicine were managed well. They told us they were aware if any staff had not provided medicines in the way they way should and had taken action where required to improve staff performance.