Forget Me Not Caring 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

People’s care was planned and delivered in a way which was intended to ensure their safety and welfare. People were protected from the risk of abuse and told us they felt safe. Risks to people's safety were assessed, although some guidance lacked detail. Systems were in place to support people with their medicines. The provider’s safety monitoring processes were not yet fully embedded and this meant lessons learned were not always used effectively to address safety concerns and ensure good practices were embedded.

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.

We received mixed feedback from partners about how effectively their feedback was used to improve people's safety and embed good practices. For example, one healthcare professional told us staff did not demonstrate a clear understanding of what their recommendations were or why they should be implemented.

People told us they were listened to when they raised concerns about safety. However, we received some mixed feedback about how learning from incidents was shared to minimise the risk of a reoccurrence. Comments included, "I think them not understanding has led to a lot of the incidents happening. They seem to either still be learning, or they just aren’t listening," and, "There had been incidents I hadn’t been aware of until several weeks down the line before, now I’m more involved. I need to be aware of things."

Staff understood the process for recording and reporting accidents and incidents. However, they told us they were not always involved in discussing incidents or deciding upon what actions to take. The registered manager confirmed they planned to implement more face to face meetings to improve this communication and promote learning.

The provider did not have a robust process in place for analysing accidents and incidents in order to identify any trends and themes. Learning was not always recorded or shared to minimise risks to people's safety.

The provider told us they shared relevant information with other healthcare professionals when making referrals and accessing other healthcare services in order to ensure people received continuity of care.

The provider had processes in place to support people to receive continuity in their care. For example, people had personalised hospital passports to take with them when accessing health services. These contained information about what was important to the person and an overview of their health needs.

Health professionals confirmed staff shared updates and discussed any issues to ensure information was transferred across to other services when relevant.

The provider told us they investigated all safeguarding concerns and kept a record of actions taken and outcomes. We found the provider had raised safeguarding concerns with the local authority safeguarding team appropriately but had not always notified CQC. The registered manager responded promptly to our feedback, raising the concerns retrospectively and putting additional checks in place to ensure notifications were sent to CQC when required. Staff told us they had received safeguarding training and knew how to raise any concerns.

The provider's safeguarding processes had improved since the last inspection; however, they were not always effective in identifying issues. For example, we found not all appropriate safeguarding notifications had been raised with CQC. The provider implemented immediate changes following our feedback to ensure more robust oversight of notifications was in place.

People told us they felt safe. People had access to easy read safeguarding policies and told us they knew how to raise any concerns.

People spoke openly about the support they received from staff and what they would do if they were unhappy or had any concerns about how staff provided their care.

People told us staff supported them to manage risks to their health and safety. One person said, "Where would we be without the staff. They do a great job. I haven't had any seizures in 18 months."

People had risk assessments in place. However, these were not always sufficiently detailed to provide staff with clear guidance about what they should do to minimise risk or what actions they should take if something went wrong. Not all risk assessments had been updated to reflect changes in people's needs. The provider responded promptly to our feedback during the first site visit and had updated the relevant risk assessments when we returned to complete the second visit the following week.

Staff we spoke with knew people well and knew how they wanted to be supported to manage risks whilst maintaining their independence.

We observed staff supporting people to manage risks safely. For example, we saw one person talking to staff about what safety precautions were in place when they went out independently on public transport.

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

The provider had processes in place to ensure staff were safely recruited with relevant employment checks completed. Staff received an induction and relevant training when starting in their roles. The provider had recently changed their training provider and training data was not always easy to review. This meant it was not always clear whether all training had been updated when required. At the time of this assessment, the provider was implementing a new training monitoring system to provide clearer data and ensure any issues with training compliance were identified promptly.

People told us staff were available to help them when required. However, we received mixed feedback from people's relatives about staffing levels and the use of agency staff. Comments included, "It’s just been staff turnover after turnover and constantly using agency, " "They need more staff and consistency," and," Now they have got good permanent staff so let's hope it carries on settling down."

The provider told us they had recruited more permanent staff and the use of agency staff had now decreased. The registered manager confirmed they had employed a recruitment assistant to support with sourcing potential candidates and this had made a positive impact to the ongoing recruitment of new staff. Staff told us they felt they had received relevant training but felt they would benefit from more specialised training to support them to fulfil their role effectively. For example, some senior support workers told us they would like more training around their staff management responsibilities. Staff told us they did not always receive regular supervision. The provider confirmed they were aware this was an area where improvements were required and had created a supervision and appraisal matrix to ensure these were monitored more effectively.

We observed appropriate staffing levels in the services we visited. Staff were visible and available to provide people with support when needed.

People were encouraged to clean their homes independently where possible, with staff providing support where necessary.

People told us how staff supported them to keep safe from the risk of infection. For example, one person showed us their easy read guidance around the risk of infections and told us how they had been supported to make decisions about COVID-19 vaccinations.

The provider had an infection prevention and control policy for staff to follow and each supported living service had a cleaning schedule in place. These schedules were audited at the end of each month to identify any concerns and ensure all cleaning was completed as required.

Staff had received infection prevention and control training and told us they had access to appropriate personal protective equipment (PPE).

People's medicines were stored appropriately and people had individual medicines folders with information about how they liked to be supported. We found people did not always have accurate, up to date protocols for medicines which were taken as and when required, such as pain relief medicines. This meant staff may not know when and how to offer these medicines. Following our feedback, the provider told us they would review this to ensure all relevant protocols were in place.

The provider promoted people's independence in managing their medicines. People were able to tell us about what medicines they took and why. Where appropriate, people had picture guides to help with identifying their medicines and when they should be taken.

The provider had made improvements to their medicines processes since the last inspection, with clearer systems in place to manage medicines safely. However, the provider's records evidenced a number of medicines administration errors were still taking place and the provider had not always completed analysis to understand why these errors were happening. The provider told us they were aware medicines errors remained an issue and were implementing more workshops and face to face staff training for each staff team to support learning and identify any particular concerns within a service.

Staff completed medicines training and the provider completed competency checks prior to them administering people's medicines.