Total Care Norfolk

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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 of this key question, we found concerns relating to staffing which constituted a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Staff were not safely recruited as the provider’s recruitment processes were not robust. Staff were not selected and interviewed in line with the provider’s own policies and procedures. People told us they felt safe, but some incidents left people open to potential risk of harm and had not been robustly investigated and learning shared. Staff knowledge about safeguarding people from abuse was poor despite recent safeguarding training. The provider did not have robust processes in place to protect people. Following a series of medication administration errors last year the provider had instigated an audit system to review medicines administration more robustly. People told us they were happy with the way their medicines were administered and records were accurate.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they experienced safe care and felt staff were well trained. They felt able to raise matters relating to their safe care and treatment, although one person was not confident action would always be taken in response to concerns raised.

Staff were clear as to their responsibilities to raise issues relating to people's safe care. However, one staff member told us action had not followed when safety concerns had been raised about one person's care. The provider and registered manager told us they tried to ensure a proactive culture was in place but we judged this incident should have been more robustly managed.

The provider had recently instigated a new system to record and analyse accidents and incidents. None had been recorded so far other than an incident resulting in a staff member missing a visit. This was well documented.

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.

The majority of people told us they felt safe and knew how to raise concerns should they need to. Two people did not have full confidence staff and the provider would always act on concerns raised.

Staff received online safeguarding training before they started to work for Total Care Norfolk and received refreshers after this. However, some staff demonstrated a very poor understanding of safeguarding and were not clear of their own duties and responsibilities despite having had recent training.The provider has repeated safeguarding training for all staff following this assessment.

The provider had not notified CQC of all potential safeguarding incidents and their response to one incident had not ensured the person was fully protected. The provider had not checked staff's knowledge and understanding of safeguarding procedures.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

People who used the service praised the skills of the staff and said they were reliable and on time. When people required two staff to support them safely they confirmed two always came. However, some told us they struggled both to understand staff or be understood by staff whose first language was not English. Although all recruited overseas staff had gained the required levels of written and spoken English to be sponsored to work in the UK, there were clearly some issues remaining. The provider was not aware of this issue and had not been proactive in the support of sponsored staff to address this. Most people said that staff were punctual and stayed the allotted time but some they wanted to know who would be providing their care in advance. One person explained, 'I rarely know who is coming even though I have asked for a rota and have rung the office and asked. At [my previous care agency] I had a rota. I get the feeling the rota is very ‘last minute’ and they don’t really know more than a couple of days ahead.'

The registered manager, although supported by the provider, had no deputy and management tasks were shared out amongst the senior carers and experienced staff. The lack of additional management staff impacted on the service's ability to monitor and audit care. We identified occasions where staff carrying out audit on behalf of the provider had found concerns, but these were not always followed up. The provider and registered manager told us they made a judgement call about the staff member providing the negative feedback rather than follow up issues. This indicated to us they were aware the staff member did not have the required skills to carry out the tasks being asked of them. However, the provider had already acknowledged that there were not enough senior staff to support the business and was in the process of appointing more. The provider and registered manager demonstrated an incomplete understanding of the regulations relating to safe recruitment. A new interviewing process had been put in place but both the provider and the registered manager had not identified the serious flaws within it. Rotas demonstrated one newly recruited staff member was placed on shift prior to being employed. Several staff were seen to be working unsupervised before checks on their practice had taken place, although they had received online training and had their suitability confirmed via the Disclosure and Barring Service.. The provider was unaware of the staff member working before being actively recruited to the role and acknowledged this should not have happened.

Staff were recruited without the required skills and experience and training was not robust. Staff knowledge and understanding of key issues, such as safeguarding, was not checked. The majority of the staff team had been recruited from overseas via a government sponsorship scheme. Robust checks on previous employment, references and qualifications had not been completed. This placed people who used the service at potential risk of unsafe care. Interview processes were not fit for purpose and consisted of a scoring scheme which was not followed and did not help identify a candidate’s suitability for the role. For example, at the end of the interview candidates received points towards a total score for stating they still wished to be considered for the role. They also received points depending on whether or not they had a holiday booked. Points were not applied consistently to all candidates. New recruitment processes were put in place following our assessment.

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.

People were happy with the way their medicines were administered and had confidence in the staff.

The provider acknowledged the monitoring processes relating to medicines needed to evidence that staff competency checks were robust.

Some medicines errors had not been identified promptly or reported to CQC, as is required. Recent improvements to the monthly audit system aimed to reduce errors. Staff underwent online medicines training and were observed administering medicines. However, where staff failed to reach the required standard, it was not clear what additional support and checks took place to address this. We noted one staff member had not reached the required standard but was now administering medicines. Records did not show further observations taking place following the initial check.