Courtyard Mews

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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 four breaches of the legal regulations in Safe Care and Treatment, Safeguarding, Staffing and Notification of other incidents. The registered manager and staff did not ensure that people received safe care and treatment. Leaders failed to assess risks to people's health conditions and safety or mitigate them where identified, putting people at serious risk of harm. People did not always have care plans to guide safe practice. People’s environments were not properly assessed to ensure that any identified risks were mitigated. People were not always safeguarded from abuse or potential abuse. The registered manager failed to notify CQC of incidents of abuse, or potential abuse in line with their regulatory responsibilities. There was a failure of leadership to learn and understand their regulatory responsibilities while delivering the regulated activity. This meant that people were not fully protected from harm. There was a failure to provide adequate training to staff to ensure they understood the conditions and health needs of the people they supported. Infection control processed and practices were often poor. Infection control processes were not thorough, and people expressed concerns about the infection control practices of staff. We identified shortfalls in the management of people’s medicines.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experience was not adequate as the service did not prioritise and involve people in the management of many risks. Risks to people’s health conditions were not assessed which meant that there was not a culture that embraced the complete safety of people being supported. One person said, “I keep telling them (care staff) and they don’t seem to listen to me. They should respect my decision.”

During the Assessment process, CQC raised serious concerns about the absence of risk assessment, management and guidance for staff in relation to the health conditions of people. The registered manager informed CQC that they did not agree that this was an area of care support that was within their remit. There was a fundamental lack of understanding and learning of both the registered manager's and provider's regulatory requirements as well as a failure to ensure risks were not ignored and dealt with appropriately to ensure people's safety.

Staff and management did not learn from safety incidents, events and findings from checks and audits. The provider's quality assurance systems had failed to identify shortfalls in the assessments of risk. Quality assurance processes did not highlight shortfalls in people's care records which meant staff and management were unable to learn from findings to improve the quality and accuracy. Risks relating to people’s health conditions were not considered important by the registered manager and people's care records lacked crucial information. For example, a person's care records did not contain accurate information about their skin integrity; there was a lack of detail available to staff about how to support the person. The person's care records were unclear on whether they had wounds, and at what stage the wounds were. This meant staff were unable to accurately monitor the person's skin integrity and escalate to healthcare professionals, this left the person at significant risk of their wounds worsening. A complaints process was in place, although the registered manager confirmed that there had been no formal complaints submitted since the last inspection.

Staff were not always aware of other services and pathways to follow in emergency situations. One staff member told us, "There was one time we went to [person's] home, they had a fall, it was 19:00 for bed calls, we called [registered manager], they picked up and directed us what to do." Delays in treatment could result in serious implications for people. The registered manager spoke about the work the service completed with a regional health team to submit referrals for specialist support when additional need had been identified. However, health and social care professionals instructions were not always included in people's care records.

Partners told us communication from the provider and registered manager was poor. They found the provider and registered manager did not work with them to ensure people's safety, and did not adopt a collaborative approach. One partner informed us of concerns around staff's unawareness of risks, lack of reporting of safeguarding incidents and failure to notify the local authority regarding a person's safety. One person had frequently not been at home when care visits were due to take place; the registered manager had neglected to advise the relevant organisations. A professional said, “There was a delay in reporting concerns or not reporting at all concerns and us finding out ourselves." They informed us that staff would have known the concerns but failed to report them. The professional further commented, “We were communicating with the agency, but it just wasn’t meeting his needs. There was a lack of communication. I would request care logs as evidence, there would be a delay in getting these." A further incident where a person had heightened incidents of distress which impacted them and those around them, went unreported to the local authority. The professional said, “This wasn't reported to us for about a week that he was experiencing this behaviour, they just called to get increase in care but not said why.”

There was a complete lack of awareness of risks and safety across people’s care journey, this placed people at risk of significant harm. The majority of people supported by the service were receiving short term care arrangements following transitions from hospital. Most people’s records confirmed they presented with health issues conditions, often complex, and whose support needs could change quickly. Although information about people’s health needs was provided by partners in care, this was not always incorporated into people’s risk assessment and care planning to ensure a joined-up approach to safety. This put people at risk of harm. Records showed that, when receiving care, referrals were made to specialist support partners. However, people’s experiences and safety were impacted by a failure to ensure that information from health and social care professionals was utilised in the care planning process and management of their support. Some people we spoke with could not be certain that they had received a full face to face assessment prior to the commencement of care, while some indicated that they could not recall these taking place. One person said, “I've never met the manager. No one came out - they did it (assessment) over the phone. Even then they were disagreeing.”

People were not safe and exposed to unnecessary harm. The registered manager had failed to ensure that incidents of abuse, or suspected abuse, were notified to the Care Quality Commission which meant we are unaware of risks, and therefore cannot consider what action was needed to keep people safe. While the people we spoke to expressed that they were generally happy with their care, our assessment found care / elements of care did not meet the expected standards. One person told us that they previously had issues with a carer not securing their property when care had finished that had impacted their well-being and safety. The person said, “The carer wasn’t closing my door properly. When she went out, she used to lock me in. I've rectified that. I told to her how to use it. It took quite a few times for her to get the hang of it. She was spoken to. It did make me cry.” Another person told us, "I don’t think i'm really listened to."

Staff and management did not have the knowledge, skills or competence to keep people safe and protect them from unavoidable harm. Despite staff and management telling us about signs of abuse and requirements to report this, records showed and we found that not all safeguarding concerns had been appropriately escalated to keep people safe. While some staff were able to tell us about reporting processes and what signs to look for as potential indicators of abuse, feedback we received from a professional indicated that staff did not always respond safely when incidents of potential harm occurred or when the person was at risk. The professional stated that staff failed to report concerns at all, or in a timely manner for a vulnerable person with health conditions that put them at risk or harm. Staff had failed to inform the local authority that the person had been missing for several days, despite being clear on the vulnerability of the person. The person was at risk of self neglect and staff did not report their concerns. The professional further told us, "[Person] had no electricity and they (staff) didn’t inform us for quite a long period." The registered manager spoke about communication with the local authority to discuss and inform them of potential safeguardings but did not have knowledge or understanding that it was a regulatory requirement for the provider to submit statutory notifications of incidents, including incidents of abuse or potential abuse, to the Care Quality Commission.

Safeguarding systems were inadequate, people were not protected from harm, and were put at risk because the provider and registered manager did not identify or respond to risk, and had not ensured that staff who were supporting people did so safely. The registered manager did not have oversight of safeguarding concerns and had not analysed concerns to identify trends and patterns. When investigations had taken place, there was no evidence of meaningful learning from the incident. For example, a person was discharged from hospital and staff were unable to ascertain whether they had received their medicines. The registered manager told us staff did not administer medicines due to risk of overdose, however, they did not take the learning opportunity to contact the hospital for a discharge summary or to ascertain whether the medicines had been administered. The provider's safeguarding policy did not provide clear information to staff. The policy advised to refer concerns to Dartford Borough Council rather than Kent County Council. The safeguarding policy referred to the provider's named safeguarding lead, however, this person was employed at the service during the assessment process and their contact details were incorrect. Should staff follow the policy there would be a delay in reporting concerns. Since the last inspection in March 2020, CQC records showed that 6 potential safeguarding concerns were raised based on information of concern that the Commission had received. CQC received a further 5 safeguarding alerts from the local authority that had identified people had potentially suffered abuse. The registered manager had failed to notify CQC of any of these potential safeguardings and had failed to submit the relevant statutory notifications for any of these individual concerns.

People did not experience care from staff who were aware of the nature and risks of health conditions they lived with. For example, people who were at risk of pressure damage to their skin did not have accurate assessments and associated care plans for staff to follow. Care records did not reflect people's current needs, this meant they could not be assured of safe and effective support. One person said, “I don’t think that they understand (immune system condition affecting the brain and spine) and I don’t know if they know anything or if they are told. It’s a bit worrying sometimes not knowing if they know. I want them to understand it. I just wonder if they do know.” One relative told us about the experience their loved one had with moving and handling had been mixed. The relative said, “(carers) just push him from one side to another. They are reasonably careful. There used to be one that was rough. I called up and said she was slap dash.”

The registered manager and staff did not understand how to manage and mitigate risks to ensure people were supported safely. The majority of people receiving care and support had complex and life threatening health conditions. Significant risks associated for people with these conditions had not been considered or assessed, these included people who lived with brain injury, anxiety, depression, type 2 diabetes, hyperthyroidism and paraplegia. There was a failure to understand the regulatory responsibilities around risk management and ensure that all risks had been considered and assessed to ensure people were safe when they received care and support. When the inadequate shortfalls in risk management for people’s healthcare conditions was raised, the registered manager stated that this area was not within their remit. Despite providing care and support to people with complex health needs, the registered manager told us that assessing risks that may arise as a consequence of those needs, was not within their remit. There was a failure to ensure that risks were reviewed and that changes to guidance for staff to follow was updated to ensure that people remained safe. For example, moving and handling risk assessments for one person indicated the person used a hospital bed and used a sara steady equipment (an aid to support people to stand) to mobilise. The person informed us that they had not used a hospital bed for two months, that their sara steady was not used and they mobilised using their walking frame. This failure to ensure risks and guidance were monitored and reviewed put people at risk of harm.

Processes to assess, record and mitigate risks to people were inadequate. There was a failure to ensure people were protected from the risk of harm and to ensure risks to people were known and mitigated. There was an absence of guidance to inform staff how to support people safely with their complex health conditions. This was unsafe and put people at risk of serious harm. For example, one person had a range of complex health conditions which included hypertension, paraplegia, spinal injury and traumatic brain injury. There were no risk assessments in place regarding these complex health conditions, or the potential risks when providing care and support. The person was at risk from pressure area breakdown, although a Waterlow assessment had not been completed (a tool used to calculate the risk of pressure ulcers developing). The persons skin integrity care plan confirmed there were concerns around their hydration needs; their fluids and nutrition care plan had not been completed. One person’s care plans indicated that they lived with type 2 diabetes and kidney disease. There were no risk assessments for staff to understand and monitor any potential risks with these conditions. There was no information about how this impacted the person or what staff needed to do to support them safely. Their care plan stated that they must kept properly hydrated, although there was no guidance or risk assessment for staff on how to monitor or manage this. Another person’s records showed that they lived with type 2 diabetes, high blood pressure and hyperthyroidism. They also lived with depression and anxiety. There were no risk assessments in place or guidance available to staff on these conditions and their potential impact. Their skin integrity care plan listed ‘unknown’ as to whether they were prone to pressure sores/areas. No other questions around skin integrity had been completed. These failures left people at serious risk of harm.

The provider had failed to assess people's environment to ensure their safety and the safety of staff providing support. Some people were unable to recall whether they had received an initial assessment of their needs from the service. When asked if an assessment of their home environment had been completed, one person said, “I don’t think they did, no.” Another person confirmed that no one from the agency came out to assess their needs prior to the commencement of their care. Without a home assessment, it was not possible for the registered manager to identify and mitigate potential hazards from the environment and equipment which may cause risks to people.

One staff member we spoke to provided information on equipment that staff use to support people within their homes. The registered manager stated that environmental risk assessments were completed and provided these for the assessment. However, our assessment found failures and shortfalls in the assessment of people’s environment that did not meet the expected standards which left people at risk of being supported in an unsafe environment with potentially unsafe or inappropriate equipment.

There was a failure to adequately assess people’s environment so that care could be delivered in a safe way. Of the records we viewed, three people did not have any completed environmental risk assessments, while others remained incomplete. Three assessments we viewed for three different people were almost identical. Each assessment contained the same information, listed the same risks and what staff should do, while none were personalised to that person’s environment.

Feedback received showed that continuity of carers for people was often poor and contrary to their expectations. One person said, “You get different carers every day. When they go, I ask them if they are coming back. It unsettles me as I like continuity. I don’t know who's coming from one day to the next which is awful. They don’t send a weekly rota. The carer can't tell me or anything.” One relative said, “They change every couple of days it'll be 2 different ones. They don’t stay long, long enough to wash him. The other visits are just 5 -10 mins, change padding and go.” Another person said, “You are never sure what time they are coming, it’s a little bit iffy.” Feedback was mixed on the skills and approach of staff. While some people spoke positively about the completion of some tasks like personal care, some people questioned the ability of staff to fully understand their needs. One person who was living with a condition that can affect the brain and spinal cord told us that some carers could be “heavy handed and needed to be carful when supporting me in the shower.” They added, “I don’t think they are getting specific training.” Another person said, “Different carers do different things. The skill level varies quite a bit.”

The registered manager told us during the assessment that when scheduling carers for people’s calls, continuity was not promoted as they wished for carers to be mixed and to ensure they experienced different packages of care. This approach was reflected in poor feedback from many people regarding continuity of care. The registered manager also confirmed that during the short-term packages that they facilitated, the service tried to move away from continuity so that it allowed carers to take time off, and “trying to avoid unnecessary bonding” in the event staff may become complacent and overlook things. The registered manager stated that they believed clients “understand that”. People’s feedback did not support this approach where continuity of care was important and necessary for them. Staff confirmed that they had received core training as part of their induction and received checks on their care delivery. None of the staff we spoke to raised concerns about, or highlighted, the shortfall in the provision of staffing, or demonstrated insight into significant gaps in their own skills, knowledge and competency.

There was inadequate training in place for staff to ensure that they had the knowledge and skills to ensure people received safe care which met their needs. People receiving support had a range of complex needs and complex health conditions. These required staff to be competent and trained in a number of areas such as high blood pressure, hyperthyroidism, paraplegia, spinal injury, traumatic brain injury, manual handling, medication administration, catheter care, diabetes care, dementia, osteoporosis, chronic kidney disease and mental health. None of the staff had received training in these areas. Staff were providing support without appropriate training; this place people at significant risk of harm. New staff went through a recruitment process prior to commencing work. Appropriate checks had been completed prior to staff starting work which included checks through the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. References were obtained from previous employers. The agency employed many overseas workers. Where a second employment reference could not be obtained, the agency sought secondary police checks from their country of origin. New staff completed an induction and probationary period. Staff completed shadowing shifts with established staff members prior to lone working.

People were not supported safely and effectively by staff to ensure that they were protected by infection. Feedback from people was poor on staff’s usage of personal protective equipment (PPE) and did not always ensure people who were at higher risk were protected. For example, one person stated that they had been diagnosed with a bronchial condition and had been told by medical staff that they needed to be free from infection. When asked if staff wore PPE effectively, the person said, “No they don’t. They sometimes wear gloves. Sometimes they have masks underneath their chin. They don’t always wear an apron. Some of them do. Its even worse now because of the condition I've been diagnosed with.” Some people told us that staff practices with wearing and disposing of PPE was unsafe. One person said, “Hygiene levels are awful. I have to remind them to wash their hands. They re-use PPE. They are turning it the other way inside out. I've made social services aware of this.” Another person told us, “Some don’t wear them (PPE). Sometimes they put the gloves on outside. I ask them not to put them back on and put it in the bin. I shouldn’t have to tell them all this.” Another person told us, “They put their gloves and apron in my green bin. I keep telling them to take the with them or put in the grey bin. They're still putting them in the green bin. There's a few gloves and aprons there the other day.” One person had previously suffered from Sepsis. Sepsis is a serious condition in which the body responds improperly to an infection. Some people who had sepsis find that they are at higher risk of infections afterwards. This is because the immune system is not as effective. The provider's infection control assessment stated that there was no known infection risk to the person. There was no information or guidance for staff on how to monitor this or respond should signs and symptoms reoccur. This put the person's safety at risk.

While the staff we spoke to confirmed that they had received training in infection control, and one staff member spoke of the importance of effective personal protection equipment, our assessment found elements of infection prevention care did not meet the expected standards. People's experience was impacted as assessments of infection control prevention were not thorough or detailed enough to ensure that people remained safe. Infection control assessments were completed for people, although some did not contain important information relating to their health needs that would require additional infection control precautions and assessment of risk.

Many people we spoke to either administered their medicines independently or were supported by a relative. However, one person we spoke to required carers to support them with a non-oral pain medication. The person said, “They do my (pain medication) when they remember. Quite often they forget. I often forget with my (health condition). If I don’t remember to tell them they forget. That should be in my notes.” While we were unable to gain further feedback from people about the service's support with medicines, our assessment found elements of care did not meet the expected standards.

Staff told us most people administered their own medicines or medicines were pre-prepared in blister packs or dossette boxes, however, people's medicine records were not always accurate and up to date to reflect this. A staff member told us about a near miss medicine error which had occurred. They said, "There is a case that happened 3-4 days back, a client called [person's name]. Whilst he was in the toilet I gave space, I popped the medication in the pot, after dressing him. I wheeled him in, he told me that their were changes to the medication. There was a new dossette box, I called the registered manager, they said he has capacity and we must follow what he wants. I documented on our notes, I write everything on the notes and I also call the office." Without up to date and accurate information, people were at risk of their medicines being mismanaged in the event that they lack understanding of what medicines have been prescribed.

Medicines were not managed safely, and this put people at risk of harm. Medicine Administration Record (MAR) charts did not always include the names of medicines, doses and strengths as recommended in the National Institute for Health and Care Excellence (NICE) guidelines [NG67] 1.5.1. Quality assurance processes did not highlight the need for details to be included on the MAR charts, for example, an internal audit assessed whether MAR charts had been completed correctly, the documented outcome was ‘MAR chart confirmed that medication is duly administered in proper dosage.’ However, we reviewed the person’s MAR chart, and the MAR chart did not include individual doses and medicines. Staff were not consistent in the way they recorded medicine administration, for example, staff used ticks, crosses or used a letter code to document administration. This did not follow the provider’s policy which stated for staff to sign MAR charts or use relevant codes to advise why a medicine had not been administered. The registered manager was not clear on which person was supported with medicine administration and who required prompting to take their medicines. This meant quality checks and audits would not highlight concerns, people could not be assured they were being supported to take their medicines safely which could result in significant harm.