Fen Homecare

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

At this inspection, the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm. We identified 2 ongoing breaches of the legal regulations. Risks to people's health and safety were still not always assessed or mitigated. Medicines were not always managed safely or administered as per prescriber instructions. Staff still had not received appropriate support and training to carry out their role. However, people generally felt safe with the care and support they received.

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.

Relatives told us they felt staff supported their family members in a way which made them feel safe.

The registered manager stated that there had not been any recorded accident or incidents. However, a culture of openness had been fostered amongst staff, encouraging them to raise any concerns or highlight areas for improvement. Staff stated that they could approach the leadership team with any concerns.

The manager stated that the organisation strives to maintain an open and learning culture. However, the inspection findings indicate that while some issues are identified and shared, for example, during staff meetings, there are significant shortcomings in how these issues are addressed. This pattern points to a lack of meaningful progress in addressing identified issues. A lack of timelines, accountability, and measurable outcomes sometimes prevents the organisation from translating discussions into meaningful improvements.

Feedback from individuals and their relatives indicated that they received the necessary support to access additional services when required. One family member told us, “Staff point out things about [relative] I should get looked at medically. They noticed a red sore on their back and their toes were red and shiny.” Another family member stated, “[Relative] had a nasty fall a month ago and didn’t tell anybody. The care staff noticed a bruise on [relative’s] head and a loss of use in one arm so phoned me, the Doctor, and 111 resulting in [relative] being admitted to hospital."

The registered manager stated that they worked with people and healthcare partners to ensure people received support when needed.

We requested general feedback from partner agencies and they did not comment on the arrangements in place regarding safe systems, pathways and transitions.

Some people received support from healthcare professionals in relation to specific health needs such as diabetes. Care plans were not always completed with accurate or detailed information about these healthcare professionals and how the service worked with them to ensure continuity.

People and their relatives were positive about their safety when staff supported them. One person told us, “Yes, I feel safe. I have no worries, nobody has ever shouted at me.” Despite people and their relatives giving positive feedback about their safety, our assessment uncovered significant concerns about the actual quality and safety of the care provided.

Not all staff had received refresher safeguarding training. While staff understood their responsibilities in protecting people from abuse, they did not always recognise that poor practice could place individuals at risk of harm. A whistleblowing policy was in place and accessible to staff.

Safeguarding concerns were not always identified from complaints or issues raised by individuals. The provider, registered manager and care staff failed to recognise potential safeguarding risks, including those arising from inadequate staff training and the unsafe management of medicines, which placed people at risk.

Relatives were positive about the care, that it was safe and delivered in a way which they wanted. Despite relatives giving positive feedback, our assessment uncovered significant concerns about the actual quality and safety of the care provided.

Staff told us they understood how to manage people’s care in a safe way. Staff told us they had access to risk assessments and had worked with people for a long time and knew them well and what the risks were. However, the registered manager did not have oversight of the risk assessment process. They had not reviewed people’s risk assessments to ensure they were appropriate or current. Risks to people’s health were not identified as a result of unsafe medication administration.

Information about some risks consisted of generic guidelines rather than being tailored to individuals' specific needs and how their conditions affected them. The required actions to mitigate these risks were not always followed. For example, 1 person’s risk assessment highlighted the need for a repositioning chart to support their skin integrity, but no chart was in place to ensure this was carried out. Following our feedback, the provider implemented the necessary chart. Additionally, risk assessments were not always in place for identified risks and if they were they were not always accurate.

People confirmed that the provider completed an environmental risk assessment.

The provider identified potential risks in the care environment; however, risk assessments did not always indicate whether necessary follow-up actions had been taken to mitigate these risks. While equipment used to support people was documented, it was not always clear when it had last been serviced or who was responsible for arranging its maintenance.

Records showed that not all environmental risks in people’s own homes had been fully identified, recorded, mitigated, and/or reviewed to ensure people, and staff, safety.

Although people and their relatives told us staff would always attend their call and would stay for the duration, they had concerns around the timing of the care calls, with some varying by up to 3 hours. They told us the timings of calls would change frequently so they did not always know day to day when staff were due. Comments included, “The parameters for breakfast call could be anything from 7-10am.” One family member stated that their relative had a tea call at 4.30pm and then a bedtime call directly after at 5.30pm. One person told us they did not know what time the care staff should arrive, but that breakfast was sometimes as late as 10.30am or 11.30am then lunch was too soon afterwards. However, some people were positive about the time of the calls. One person told us “They’re spot on time or within half an hour. They call if they’re going to be later.” In relation to safe and effective staffing, 1 person told us, “In an ideal world staff would be trained more across the board, including the use of language”.

The provider placed people at risk of harm by failing to demonstrate that staff had the necessary training and skills to support them safely. Staff had not received the required training to administer specific medicines, manage health and medical conditions, or fully understand their responsibilities. Additionally, we identified that staff rotas did not always allow sufficient travel time between visits, potentially impacting the quality of care. In response to our findings, the provider stated that travel time had been increased.

The provider’s processes did not demonstrate that staff had the necessary skills and experience to effectively support people. While electronic call monitoring showed no missed calls, arrival times varied frequently, preventing people from planning their day reliably. Additionally, care calls were not appropriately spaced to ensure medication was administered at the correct times. The registered manager and provider had not monitored call times to address these issues.

The provider usually followed safe recruitment checks. The reason for gaps in employment history had not always been recorded.

People and relatives told us staff wore appropriate personal protective equipment to reduce the risk of infection spreading.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had an infection prevention and control policy, and staff had access to personal protective equipment (PPE) as required. Staff had received training in infection control.

People told us that staff administered their medications and reminded them or their relatives if stocks were getting low so they could be ordered. Despite people not having any concerns regarding their medicines, our assessment uncovered significant concerns about the actual quality and safety of the administration of medicines.

Staff had completed training in the safe handling of medicines, however safe procedures were not being followed. The provider did not regularly complete competency or quality checks on staff and records to ensure that the right person had received the right medicine at the right time.

People had been put at risk of not receiving their medicines as prescribed or intended, we saw evidence of this and medicines being given too close together according to their instructions. Some people had medicines only when they needed them, such as pain relief. There was a lack of information for staff to know when or why they should administer these medicines. The risks associated with specific medicines had not been assessed, which put people at risk of avoidable harm. The discrepancies in medication administration highlight systemic failings in staff training, oversight, and quality assurance. These failings pose a significant risk to the health and well-being of people.