CLARITY HOMECARE (BRISTOL)

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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 assessed 5 quality statements in the safe key question. We identified 3 breaches of regulations. Staff received safeguarding training and knew what to do if they had concerns. Systems had recently been created, but there was no consistent recording of safeguarding issues or actions before this. Some incidents had not been notified to CQC as required. Although improvements were being made, this was a breach of regulations relating to safeguarding. Staff understood the risks faced by people. However risk assessments were not always comprehensive or up to date. This put people at a risk of harm because staff did not always have appropriate guidance to follow. This was a breach of regulations relating to safe care and treatment. Medicines were not always managed safely. We found errors in records and missing information. Audits had not identified the shortfalls we found. Changes were made to improve standards. There was no evidence that people were harmed, but this was a breach of regulations relating to safe care and treatment. The provider did not consistently follow safe recruitment processes and there were gaps in records and checks. Managers had identified shortfalls and were making improvements. Staff were positive about the changes. However, this was a breach of regulations regarding the employment of ‘fit and proper’ staff. Most people were not satisfied with the staffing levels or timing of their visits, although staff and managers told us there were enough staff to support people. Some visits to people were regularly shorter than they should be. We received positive feedback about some staff. People were happy about the support they received with their medicines. Managers responded proactively to our feedback about the shortfalls we found. They had made changes, but recognised further improvements were required.

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.

People said they did not always feel safe or supported to understand and manage risks they faced. They told us that staff did not always seem trained in how to carry out their role. Comments included “If new carers are introduced to the rota, there is no shadowing with a carer that knows my routine. They have to be guided and shown the routines by myself” and “There needs to be more training in manual handling and complex care.” Some people said they had no concerns and would be happy to raise any issues if necessary.

Leaders told us they were aware of issues at the service and had responded by bringing in senior and experienced managers to make improvements and ensure good practice was embedded. They told us about examples of improvements which had been made. The management team responded proactively to our feedback about the areas for improvement we identified during the assessment.

We found incidents had not always been documented or actions followed up. Some incidents had not been notified to CQC as required. New systems had been recently introduced, but we could not be assured that lessons had been consistently learned following safety incidents or that improvements had previously been put in place when necessary. The provider had started to carry out checks and increased the support given to the service to promote a positive culture of safety where concerns were reported and investigated, and lessons learned to make improvements. The provider’s action plan noted that there had been improvements in the way incidents, complaints, safeguarding, compliments and audits were recorded and actions taken. However, they also recognised that further and ongoing changes were required.

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 gave us mixed feedback about how their safety, wellbeing and human rights were protected. One person told us, “The carers don’t take the purse to put my money in when they go shopping, they put money in their pocket, so it gets mixed up and there are lots of people that know my bank code.” However other people said, “I do feel safe now as the continuity of carers has now improved” and “I feel safe with them as they know my routine.”

Staff confirmed they had access to safeguarding procedures and had received training. One staff member told us, “Yes I do have access to safeguarding policies and training.” Some staff had completed courses to enable them to deliver safeguarding training to their colleagues. Staff told us about how they would report any safeguarding concerns. One staff member said, “I would report to my manager and the team who would raise a safeguarding to the relevant authorities.” Another explained, “I always monitor interactions and ensure that my colleagues and I follow the safeguarding procedures. I would also whistle blow if there was a major concern that’s coming from my colleagues when I work with them.”

Systems and processes to make sure people were protected from abuse and neglect were not effective or consistently used. When we asked to view the safeguarding file, we were told there was not one. We saw a log of safeguarding concerns, but this contained no detail about the incidents or description about what actions had been taken. A manager told us a new safeguarding log had recently been introduced. We were told about financial concerns relating to a person and found these had not been appropriately investigated or reported by the provider, and necessary actions had not been taken to manage risks. For example, the person’s risk assessment had not been updated and the local authority safeguarding team had not been informed. Another more recent incident relating to a person’s medicines had been appropriately reported, recorded and shared with the local authority safeguarding team. Improvements to safeguarding systems and processes had been put in place, but these needed to be embedded to ensure people were protected. The Mental Capacity Act 2005 provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. People’s capacity was not always documented in their care records, and legal information about decision making authority was not always clear. This had been identified by the new management team and processes were put in place to improve consistency.

We received mixed feedback from people about how they were supported to understand and manage any risks which related to them. One person told us, “The manager has been out to review how things are going”, but another person said, “I haven’t seen a manager for ages, in fact can’t remember if I ever have.” One person wanted to be able to see what was being written by staff in the electronic records, but they told us, “I have had no luck as yet getting access to see what they write about my care.” Staff told us processes had been introduced to improve people’s access to records after the assessment. People told us risks relating to specific needs had not always been assessed. One person said, “There have been no risk management assessments completed for manual handling and use of the other equipment that I need to transfer from bed to chairs."

We asked staff if they were aware of how risks were assessed and if risk assessments were in place for people. We received varied feedback. One staff member said, “No time to read it. They give us information”, but another told us, “Yes, they do provide enough information, and we do have time to read risk assessments.” One staff member said, “I have no concerns regarding the safety of the people we support as I believe that we work hard to ensure we do our best to support people safely.”

Although risk assessments were in place, these were not always comprehensive or up to date. For example, risk assessments relating to medicines and health needs, mobility, swallowing risks and financial safety lacked detail or had not always been recently reviewed. Some people had medical conditions which needed monitoring, but there was a lack of guidance for staff to know what they were looking for or checking. Although there had been recent problems with one person’s medicines, the medicines risk assessment had not been updated for 2 years. One person had choked when eating, and staff intervened to successfully remove the blockage. However, there was no information about what the person was eating, how they were after the incident or whether any medical advice was sought. There were no risk assessments in this person’s care record relating to eating and drinking. In other cases, there was a lack of detail in the risk assessment. For example, more specific guidance was needed about how to safely move one person. More information was needed about how to support a person who experienced seizures. The lack of detail in these cases put people at a greater risk of harm because staff did not always have specific and relevant guidance to follow. People’s care records contained some information about safety in the home environment, but these did not always describe the risks which might be faced by people or what staff should do to reduce risks or respond in the event of an emergency. The operations manager told us they were aware of gaps in care records and were in the process of reviewing all care files and meeting with people and their representatives to make improvements.

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

There should be appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that meets their needs. Some people gave us negative feedback about staffing levels and the timings of their visits. Comments included, “They need to improve on their timekeeping for the calls, as it is so variable” and “The carers always seem to be in a hurry, so I feel quite rushed.” One relative told us, “They just come in and brush her hair. They are in and out in 5 minutes.” We saw evidence which suggested the duration of some people’s visits were regularly shorter than they should be. One person explained that they did not have the access to the local community they wanted because the provider could not provide staff with the necessary skills to be able to meet the person’s needs. We received mixed feedback about staff. Some people felt staff were kind and respectful and made positive comments including, “I have a regular carer that I trust and know well” and “I am treated with dignity, particularly when they help me shower. They are respectful and try to give me as much privacy as possible.” However, some people’s feedback was less positive, such as, “Most of the carers are very pleasant, but some can just sit watching their phones and do not talk to me. I need the companionship and want the carers to interact and be sociable, but not all of them do” and “I asked them to mop the floor the other day and they just said they didn’t have time.”

We asked staff if they felt there were enough staff. Their responses included, “The staffing levels are okay, I have not heard any complaints” and “I believe the staffing levels at Clarity are generally adequate, but there can be times, such as during unexpected absences, when we could benefit from additional support. This would help us maintain high-quality care and give more attention to each resident.” We were told the care co-ordinators would cover short term absences. The operations manager confirmed there were sufficient staff to support people, and ongoing recruitment at all levels was taking place. They hoped this would support the growth of the company. We asked staff if they received an induction. Feedback included, “Yes, I had one, but it did not cover everything” and “Yes, I had an induction that covered many essential aspects of my role. While I felt mostly prepared, I did appreciate additional guidance in the early days to help build my confidence in working unsupervised.” Staff we spoke with told us training had improved recently since new management staff had been recruited. Staff confirmed they received supervision and spot checks, and this had also recently improved. One staff member told us, “Before, there was no sense of direction, and we have direction now. The manager is listening and tries to help us.”

The provider did not consistently follow robust recruitment processes. We found discrepancies in staff files such as missing application and interview records, interview notes not completed or scores checked to ensure staff met expectations, and gaps in employment which were not always explored. In addition, there were a lack of pre-employment checks. This included insufficient references and missing criminal record checks. This placed people at risk because the provider could not be sure all staff were suitable, competent or skilled to carry out their role. Staff had completed some induction and training, but this was not comprehensive and did not always reflect the needs of the people they supported. According to the records we saw, some staff had been in post for many months before completing any training. The operations manager said that they had audited staff training and found significant gaps. They also knew more face-to-face training and checks of staff competency were needed. To address this, 2 staff had completed ‘train the trainer’ courses in moving and handling, basic life support and safeguarding, and staff compliance had improved. Training was being rolled out to all staff and competency was being checked. We reviewed the records of visits to people, and these showed staff were not always staying for the full amount of time. For 3 people, some visits were less than half of the allocated duration. Some visits started 2 hours earlier than they should have. We discussed this with the operations manager, who said it had come to their attention that care staff were changing times to suit them rather than the person’s needs. This was being addressed with individual staff.

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.

Feedback from people about the medicines was positive. Comments included, “I know exactly what tablets I have to take and when, so I do check that the carers have the right tablets before they give them to me”, “They come on time to help me with my tablets as I forget to take them” and “I have had no problems with medications.”

Staff told us they received training about the safe management and administration of medicines. They said they were aware of what to do if a medicines error was made. Their comments included, “I do administer medication. I received training to do medication administration. I practice every day in client’s home” and “If there is a medicines error, I would see if my client is feeling good. If not I will call 999 or 111 according to the situation and after that I will inform my managers and care coordinator.”

People's medicines were not always recorded, and adequate medicines administration records were not in place when staff supported people. Risk assessments relating to medicine management were not completed. There was a lack of person-centred guidance about how each person liked to take their medicines. There were no body charts to help staff know where to apply creams, although this was part of the person's assessed needs. We saw there had been a serious medicines error, but the person’s risk assessment and care plan had not been updated to mitigate any further risks to the person. There was no record of the incident in the person’s care record. There was a lack of reporting to other agencies to protect the person or ensure safeguards were in place. The person did not miss any doses of their medication and suffered no harm. The provider has since made improvements to processes. According to the records we saw, not all staff had been assessed as being competent in medicines management, but they were administering people’s medicines. The provider had completed 20 individual medicines audits in the month before our visit. Although this was an improvement, they noted that further improvement was required and their action plan expected care coordinators to complete at least 5 audits per day.