East Anglia Domiciliary Care Branch

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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

The provider had not ensured there was an effective system in place to ensure people’s risks were managed effectively and plans put in place to mitigate these and ensure they received the care and support they needed. Where incidents and safeguarding concerns had been reported, lessons had not been learnt or improvements made. This had resulted in breach of Regulation 12. We found restrictive practices which constituted breaches of Regulation 13. There was high use of agency due to the lack of staff. Although, wherever possible the same agency staff were used, they and some existing staff, did not all have the legal required training on learning disability and autism or the skills to provide the specialised care to people. Agency and existing staff did not have their competency checked to provide care and for administering medication. This resulted in breaches of Regulation 18.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We had a mixed response from people and their relatives. Some felt if they had any concerns or complaints they would be listened to. However, in the majority of cases, relatives did not know who to approach if they had any concerns and this gave them no confidence that they would be listened to. In one home relatives spoken to said they did not know who the manager was and could not get hold of staff. One said, “Not sure who to contact, don’t know who manager is. Dare not raise any complaints, don’t want to make a fuss. Hope [person] is ok. I leave messages and they are not answered. Nobody phones me.”

Staff did not always feel supported by leaders or felt listened to. Staff who had raised concerns were not always listened to, supported and their issues fully investigated. In one case a staff member had raised concerns which were not fully reviewed at the time, but then were subject to a safeguarding investigation later when they came to light in a different way.

There had not always been openness and transparency from the provider. We identified incidents which should have been safeguarding. The Local Authority also identified there had been safeguarding incidents which had not been reported to them and they had not been informed about changes to management of services.

We found there were no processes in operation for reviewing incidents, behaviour or events to learn and improve care provided. For example, for one person there should be antecedent, behaviour, consequence (ABC) charts completed to review triggers for how they responded. However, we found entries in daily notes which should have had ABC charts completed. Therefore, there was no review to see if the approach of staff was impacting on how they reacted and presented, and whether changes were needed.

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.

Whilst relatives and people did not raise concerns with us directly, other evidence showed people were not always kept safe from abuse. We found people had their finances spent on inappropriate items without their consent.

Staff spoken to said they would report any safeguarding concerns. However, staff did not recognise dubious practice around intimate personal care without the person’s consent as potential safeguarding concern. In another home we found the front door locked despite most people being wheelchair users. When the staff were asked why this was in place they said to keep people safe and from leaving the premises and it had always been this way. This was not the least restrictive practice.

We observed a number of incidents whilst we visited people’s homes which staff had not identified as putting people at risk. This included staff using a drag lift to reposition a person which was not appropriate and put the person at risk of harm.

Effective systems, processes and practices were not always in place in relation to how people spent their money. Records were in place with receipts when people’s money was spent. However, the decision making around spending was not clear. Records relating to best interest decisions were not in place. There were occasions when people were paying for staff entries to events, but records did not support decision making for this. People were also routinely paying for staff refreshments whilst they were being supported in their own home and for stationery and Personal Protective Equipment (PPE), which was inappropriate.

Although most of the people and their relatives did not raise concerns, some did identify areas of risk they were not sure were being addressed. One relative, who did not have confidence in most of the staff, said they were not sure if staff understood the person’s needs regarding eating or dietary needs. They had not got any teeth and were losing weight. We did not see evidence that people were involved in the management of risks.

Risks around people’s care were not always managed in a safe way. Staff and managers did not always feel it was their responsibility. For one person who had lost a lot of weight and whose mobility had declined, staff told us there was nothing in place to support the person to improve as the learning disability nurse looked after this at their weekly visit. There were no considerations to what actions staff might need to take, such as ongoing weight monitoring, or nutritional changes to help support this person.

We observed on visiting a home that due to a person’s anxious behaviour which led them to use the toilet frequently, the toilet door was locked at certain times to stop them doing this. The person lacked capacity to consent to this. There was no capacity assessment or best interest decision to involve others and there were no plans identifying this as the least restrictive option.

People’s risks were not always risk assessed and updated as effectively as they should have been. One person had sustained three falls and actions had not been taken to look at any root cause analysis or mitigate to prevent a reoccurrence. The same person had a walking frame that had not been appropriately assessed for their usage.

We found people’s homes were often cluttered. This was largely due to the storage of paperwork and items for staff. This was not following the Real Tenancy Test with regards to people having control of what happens in their own home.

In one supported living home we found two people sharing a bedroom in someone else’s support living accommodation. Although this was initially a short term emergency this situation had gone on for some months. When we spoke to staff about this situation we were told the decision had been made as a result of staffing levels as some staff had left the service without any notice. The decision making around this was not clear and did not respect their human rights. This was also not in line with the Reach standards which sets out the rights for people in supported living.

We found in a number of the homes bedrooms, or parts of communal areas, such as conservatories were being used as staff offices. This impacted on the space people had in their own homes.

We visited another home where there had been issues with the heating and it was not working. Portable heaters were in place but there was no risk assessment to ensure all measures were in place to keep people safe. One of the people had visual impairments. Another was cared for in bed and there were no further checks to ensure they were kept warm enough.

The majority of relatives spoken to identified there had been an increase in agency staff due to lack of staff which had led to an impact for people especially in relation to the activities they undertook. People have not attended such things as the gym, football matches, walks and outings in their car. Some of these things had been pre-paid for. This, in some cases, had led people to be anxious about leaving their home and undertaking things they once enjoyed.

Staff spoken to did not all feel supported within their roles. There had been recent changes which had resulted in managers being spread more thinly between the homes and with sickness and absences this had left the remaining managers being overstretched and staff feeling unsupported. Some managers felt there were knee jerk reaction when making decisions when things happened which then were reversed later, which led to confusion for staff.

When visiting homes there was not always allocated staffing numbers on and high numbers of agency staff. One home we visited should have had 4 staff working and there was 2 agency staff, and one bank staff for the morning shift. The agency and bank staff where possible, were regularly used so they did get to know people. We were unsure whether staff had received appropriate training for their role. When we observed poor moving and handling techniques, we asked about the staff’s training and competency checks to practice. The staff had received training 16 months before and had not had any competency checks on their practice. We felt this put people at risk of harm.

The provider had failed to ensure there were sufficient numbers of trained staff to ensure people’s safety. We identified a number of homes were there were insufficient staff trained to people’s needs for such things as epilepsy, administration of medication, especially for epilepsy, and RIG feed, and at those homes, times when there were no staff who had this training on shift for up to 16 hours. Although some agency staff had received training this was not all of those who were used regularly. Some had not even had received the required training in learning disability and autism. There was a lack of competency and oversight of training and no corporate training programme so it was difficult to identify at what intervals training should be. There was also no record of competencies undertaken. This all put people at risk of being inadequately support by staff insufficiently trained to meet their needs.

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.

Whilst relatives and people did not raise concerns with us directly, other evidence such as a lack of paperwork for such things as ‘as and when’ (PRN) medication and not always gaining guidance from health care professionals, meant people could be at risk of their medication not being administered safely.

On visiting a service, we identified guidance for medication was inconsistent between documents. For one person their list of medication stated their levothyroxine should be given 30 minutes before food and other medication. However, their medicine administration record (MAR chart) stated the time for this medication was the same as other morning medication with no reference to being 30 minutes earlier. When asked staff they showed a sign on the inside of a kitchen cabinet which referred to the correct time for the medication to be given, which they said they referred to when giving medication. As there was high use of agency staff, we were concerned the inconsistencies would mean the medication was not given when it was required.

On visiting homes staff spoken to explained and had an understanding of the medication process. However, we saw gaps in the process to keep people safe. This included liquid medication opened without having open dates recorded, and some types of medication regularly not being counted in a number of homes.

An audit completed on 12/03/2024 identified 3 people in one home, did not have protocols for PRN medication in place. However, this had not been actioned when we checked the records as part of the assessment. We also identified shifts in some homes which did not have any staff on shift who were trained to administer medication. This meant people may not receive the medication at the times they required it.