Copthorne Complete Home Care Limited

On this page

• 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 the legal regulations. The provider continued to provide poor care. We found people were still not protected from abuse and improper treatment. Risks to people's health and safety were still not always assessed or mitigated. People’s care plans still did not guide safe practice and the management of medicines was not always safe. Staff still had not received appropriate support and training to carry out their role. Incidents were not investigated therefore lessons could not be learnt from safety events. However, people felt safe with the care and support they received.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they felt staff supported their family members in a way which made them feel safe.

Staff were not aware of the policy or processes for investigating incidents or accidents. Staff told us they reported any bruises and injuries on people verbally to the registered manager and that their [staff] responsibility was to complete a body map to show where the injuries were. They received no feedback or outcomes which could help the organisation or staff to learn lessons because the registered manager did not investigate safety events.

The provider did not have a proactive or positive culture of safety. They did not have systems or processes to identify, investigate or learn from safety events. Body maps recorded where marks and injuries had been observed on people, but there was no investigations into the causes of any injuries. The registered manager could not evidence they reviewed people’s risk assessments or care plans following the identification of injuries. By not reviewing accidents and incidents to learn lessons, the provider put people at risk of avoidable harm.

Relatives felt staff worked safely, including the provision and use of equipment.

Staff did not have the opportunity to read peoples risk assessments. They were told what to do by the registered manager and did not routinely read people’s care plans. Staff had been assessed as competent in their roles; however they had not been assessed by someone with the necessary qualifications and competencies. This put people at risk from unsafe and inconsistent practice. The registered manager could not provide evidence they were qualified to assess staff in moving and handling practices, or that they had been assessed as competent.

The registered manager did not work in partnership with other agencies to ensure the safe care and treatment of people. For example, where there was an allegation of abuse, this information was not shared with the local authority safeguarding team to ensure the person was safe.

People were at risk of not receiving a consistent approach to their care because the provider did not always maintain safe systems of care. The provider did not always provide staff with the information necessary to perform their roles.

People and their relatives were positive about their safety when staff supported them. People’s relatives found the care and support was delivered in a safe way and staff knew how to safely support their family member.

Staff had attended training in abuse but did not have access to a safeguarding policy, and they were unaware of their responsibility of safeguarding people from the risk of harm. Staff would share any concerns about potential abuse with the registered manager. However, the registered manager lacked understanding of their responsibilities of safeguarding people from abuse and poor practices because allegations of abuse had not been acted on appropriately or in a timely manner. The provider did not ensure information and discussions regarding people remained private and confidential and was only accessed by those with the authority to do so. An unauthorised person was privy to confidential information about a person who used the service. This demonstrated the General Data Protection Regulation (GDPR) was not adhered to. Staff and the registered manager had received training in the Mental Capacity Act (MCA). However, this learning had not been used to support people to understand their rights, including their human rights, under the Mental Capacity Act 2005 (MCA) and their rights under the Equality Act 2010.

People were placed at risk of harm because the provider did not take appropriate action when abuse had been alleged. Information was not shared with the appropriate agencies for action to be taken to mitigate the risk of further abuse. The registered manager did not work with people to understand what being safe meant to them or how to achieve this. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The providers’ safeguarding policy was initially not found and when found, contained inaccurate information regarding important contact details. The lack of available and accurate safeguarding information, policy or procedures put people at risk of abuse and improper treatment as processes to ensure their safety were not known.

Relatives were positive about the care staff delivered, that it was safe and delivered in a way which they wanted. Environmental assessments were completed at the person’s property and one relative told us access arrangements were looked at. However, they said, “I don’t think there is anything written down, we have not seen it anyway.”

The registered manager did not work with people to understand and manage risk by thinking holistically. Staff did not have access to risk assessments to aid their understanding about potential risks to people. One staff member told us they did not read people’s risk assessments because the registered manager told them what needed to be done. They said, “I don't know where I would find them, I think they are in the folder.”

The provider did not have the processes in place to identify, review or mitigate risks to people. People were exposed to avoidable harm because the provider did not effectively assess and manage risk associated with their environment, mobility, risk of falls, skin damage, catheter care or health conditions. The provider failed to evidence clear and accurate risk assessments for staff members to follow in order to provide safe care.

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

Relatives of those receiving care and support felt the staff arrived on time, stayed for the expected duration, and told us they did not have any concerns.

The provider put people at risk of harm because they could not demonstrate staff had the necessary training and skills to safely support people. Staff had not received the training they needed to support people with specific medicines, health and medical conditions and to help them understand their responsibilities. Staff provided a service to people with a learning disability. The provider had failed to ensure staff had received recognised training to support people as individuals, despite initially telling us they had. This put people at risk of receiving care and support from staff who potentially failed to understand or respond to their specific needs and preferences.

The provider’s processes did not evidence staff had the necessary skills and experiences to effectively support people. Staff administered specific medicines and undertook checks, but the provider could not provide evidence these staff had been trained or assessed as competent to do so. The registered manger could not provide evidence they were competent to assess their staff's practice regarding moving and handling or the use of equipment. The provider followed safe recruitment checks.

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.

Not everyone required support with their medicines. One relative told us they were happy with the support staff gave to their family member and did not identify any issues.

Staff had completed training in the safe handling of medicines. However, the provider did not complete competency or quality checks on staff and records to ensure that the right person had received the right medicine at the right time. The registered manager could not provide evidence they were trained and competent to monitor and administer a specific medicine, which put people at risk of harm. We shared this information with the local safeguarding authority and the Nursing and Midwifery Council (NMC).

The provider’s processes did not support the safe management of medicine. They failed to identify safe practices for the administration of insulin, prescribed creams or other medicines. People had been put at risk of not receiving their medicines as prescribed or intended. Some people had medicines only when they needed them, such as pain relief. There was a lack of information for staff to know when or why they should administer these medicines. The risks associated with specific medicines had not been assessed, which put people at risk of avoidable harm. No protocols were in place to monitor the use of prescribed creams and ‘as needed’ medicines.