Smartway Health and Social Care Limited

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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 2 breaches of regulation in relation to shortfalls in the how staff were safely recruited and in how the service ensured there were sufficient numbers of staff employed to meet the needs of people being supported. There were shortfalls in the management of medicines as accurate records were not being maintained and competency assessments were not being completed to ensure staff were safely administering medicines to people. People were not clearly involved in decisions around their initial care and risks were not always safely managed as guidance around how to support a person was not always comprehensive and detailed. Staff were not always attending people at the times needed and did not always stay the allocated time which impacted upon people’s safety and the quality of care people received.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were unclear of how processes were used to support learning. Staff told us they felt able to raise concerns but told us historically these had not always been effectively managed. One member of staff told us of concerns they had in relation to how new staff were supported in their role to ensure they had a good understanding of care and expectations of their role. However, staff were not aware of how these issues had been addressed and improvements had been made as part of an induction processes. Following our onsite assessment, the registered manager shared how they had fed back to staff findings from our visit as part of a meeting. This included discussions about various ways the service can leant and improve. It was not evident that such processes had been in place prior to our assessment.

Systems were in place to ensure accidents and incidents were reported appropriately and reviewed by the registered manager. However, the provider had not conducted overall analysis of these events to identify themes and trends and reduce the risk of reoccurrence. Following our assessment the registered manager provided a document called ‘Lessons learned’. This included discussion around the impact of staffing levels, difficulties in the systems used by the service and staff training and support. However, there was no evidence to show quality assurance processes were in place and being used effectively to learn lessons and drive improvement prior to our assessment.

People’s feedback did not evidence a practice approach to lessons learnt was taken or that people were involved in such processes. Some examples given by people included that lessons were not always learnt, for example around staff behaviour. One relative said, “[We} did speak to Smartways and I have no idea if anything happened. That carer has been back.” However, other people and relatives fed back examples where staff had been proactive in sharing information, for example around the maintenance of lifting equipment with the relative commenting, “They have been so informative to me.” Feedback from people indicated significant concerns in relation to call times but this had not been identified or resolved by the service by the time we visited to assess the service.

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.

People were place at potential risk of abuse due to late, early, and short calls. The service had no suitable framework in place in order to review people’s calls. The registered manager was aware many staff were not using the call management system correctly, but this poor practice continued. Safeguarding concerns were minimal at the service, but we could not be certain the service had suitable systems to ensure oversight and safeguarding processes were followed. There was no evidence of the service alerting the local authority when systematic late and short calls continue to happen. Safeguarding training was in place and had been completed by most staff at the service.

People’s feedback about the safety of the service was mixed and included concerns about call times and durations. This meant people may not have been receiving the care they needed in a timely way and may not have had care delivered in line with preferences and wishes due to time shortage. People and relatives generally spoke positively about the majority of the staff and felt safe supported by them. One relative commented, “[family member] has a regular carer who is marvellous. Very caring following up with updates and medication. Some of the relief/fill in carers don't know them as well. They have WhatsApp groups when they update each other, or I phone the office and they update carers. The main carer is there for the full time. Time keeping is not as long as it should be… [sometimes] they are in and out.” And another relative told us, “They all treat [family member] as if they were their own. Sometimes they don't know they are there, and they come in and call out. I can go away and know they are in good hands.” However, this was not the case for all staff supporting people. One relative commented, “I think some of the carers are more sympathetic than some.” Whilst another commented, “The carer we have concerns about does the bare minimum. we don’t feel the carer is competent. We will make sure [family member] has their lunch if the carer turns up.”

People were not safeguarded from the risk of abuse, due to late, early, short and missed calls and the systems were not always effective in ensuring oversight and shortfalls were identified and addressed. Staff had completed training in this area but did not demonstrate that they had a good understanding of principles underpinning safeguarding or when to escalate concerns.

There was limited involvement from people and their relatives in identifying risk and needs and developing care plans. The service relied on social worker assessments in order the create the care plan and risk assessments. People and relatives were generally positive about the care people received and felt safely supported. One relative told us, “No quibbles. The staff are first class. I have been unwell and if I didn't have the staff in place I would be in concern.” However other relatives fed back, “By and large okay, varying degrees in the quality.” And another commented, “At the moment it's okay.. We have issues in the past with staff cooking meals…. Its more nighttime staff with his meals they are not always clued up.” This meant that people and relatives did not consistently feel they were receiving the support needed in a safe way.

There was no evidence that people’s needs were assessed by the provider prior to commencing support. Care plans were in place but did not consistently provide enough detail on how people needed to be supported. For example, details about how a person needed their food and drink to be modified in order to eat and drink safely, were not clearly reflected within care plans which placed this person at risk of choking. People’s risk assessments lacked detailed information about how these risks could be minimised and how to support people to keep them safe and protect them from any avoidable harm. For example, one person had a nutritional risk assessment in place. However, it was not clear how this risk was assessed, what measures were in place and what impact this had on the person. This increased the risk of people receiving unsafe care.

Staff told us they completed training around health and safety. However, this training was not followed up with assessments of competency to ensure staff understanding. Staff discussed examples where people had not received the support they needed in a timely way, due to lack of appropriate equipment or training. One member of staff told us, “[Some staff] are not good with the hoist; one carer doesn’t understand the concept of the hoist and a family member of a service user had to help.”

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

Staffing levels and rota systems were unsafe. The provider's electronic call data demonstrated clear and widespread evidence of significantly late, early, short and missed calls. There was systemic and widespread evidence of unsafe practice. Staff were scheduled to be at multiple calls at the same time or back-to-back calls without any time for travel. One fifth of calls were either scheduled with no travel time or at the same time as other calls. This meant it was inevitable people's calls would be late or missed and staff stayed for less time than scheduled. Across the service, more than half of people's planned care time was not delivered. We identified significant concerns in how the call management system was being used by staff. The registered manager and provider had no oversight of call monitoring and were not aware of the major issues with their system. The provider had not followed safe recruitment practices. Gaps were found across recruitment records, including within application forms, gaps in employment histories and references not sought from details provided. Training was in place and most staff were up to date with training which had been allocated to them. However, shortfalls in the training provided were identified and that training was not in line with best practice guidance. There was evidence that the training provided was insufficient to ensure staff understood and were competent to provide care. For example, staff completed food safety training but not all staff had a good understanding of how to cook and prepare meals in a safe way. One staff member told us:” The training is online. Some staff may need more.”

People and relatives told us there was generally about having a consistent staff team and most staff knew people and were competent. However, feedback indicated this was not consistently the case, with people noting some staff were better than others, there was a language barrier and themes in relation to calls being late and staff not staying the full time were frequently identified. One relative told us, “Four of the carers are excellent, 2 good and 2 not very good. One is ready to leave before they have arrived and sometime doesn't do anything.” However, another relative commented, “I have timed it to see if we can give up any more time. I did a chart, and they [staff] use every minute. [family member] has put weight on, and I don't think they would have lived for as long without them coming in.’ The feedback from people indicated that there was not always sufficient staff to ensure people received their calls on time and staff were able to stay for the time commissioned. People were not always confident that staff were competent and capable to meet their needs. One relative commented, “My 3 permanent staff are trained properly, I think the majority need more training. Especially with the hoist, they seem to struggle.” Another relative told us, “I don’t think they are well trained; I leave them to do it.”

Staff told us they felt supported in their role. However, there was limited evidence that staff received structured support through supervision with records indicating no members of staff had received formal supervision in the past 3 months, and staff confirmed they had received no recent supervisions. Some staff also felt there was a divide between the new staff on sponsorships gaining more care hours, these matters had not been resolved by the service.

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

Medicines were not managed safely. Electronic medication administration records (eMARs) were not sufficient to ensure possible risks with administration were mitigated. Medicines administration records (MARs) did not always include important information. For example, people's allergies were not recorded on the MARs we reviewed. Medicine doses were not recorded, and it was unclear what time the medicines needed to be administered. Prescribed creams were entered on the spreadsheet records, there was no information recorded to state where the creams needed to be applied. The provider had a system for assessing the competency of staff to administer medicines safely, however we found the competency assessments for many staff were not up to date.

Staff felt they had the appropriate skills to support people with their medicines. One staff member commented, “Yes, we have training to ensure that they are administered safely.” Although staff felt confident administering people’s medicines, we were not assured staff had received the appropriate medicines competency and understood risk in relation to people receiving medicines in a timely way.

People were not consistently receiving safe support to take their medicines. Some relatives told us people got their medicines appropriately and staff would ask them to reorder medicine, which was running out, and let them know if they were running late. One relative commented, “They are on to me straight away to reorder [medicine].” However, people also told of examples where medicines were being less safely managed. One relative commented, “I have found one tablet on the table, and we told them. We have asked them to ensure [family member] takes their medication. I think they are monitoring it.” Another relative commented, “I do [family members] medicines, I don’t trust them to do that.”