Archived: Assisted Care Solutions LImited

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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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.The service was in breach of legal regulations in relation to people’s safe care and treatment, safeguarding, staff training, deployment and recruitment, the ways people’s medicines were managed safely and managing incidents and concerns at the service.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety, based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learned, which limited the ability to identify and embed good practice consistently. We reviewed people’s daily notes and found staff recorded concerns and noted they had informed management of these. The registered manager told us staff were aware of the importance of raising issues about people’s needs, changes, or anything they noticed, and would put this on the system. We saw examples of staff noting if people’s needs changed, or if they noticed something that raised concerns about people’s health and wellbeing. However, there was no clear evidence the registered manager acknowledged, logged or investigated these events to ensure lessons were learnt and discussed with staff to continually identify any improvements and embed good practice. The registered manager told us the current system and process of learning culture from accidents, incidents and complaints was “not good enough at the moment”. We found 14 incidents in people’s daily notes that were not logged on the system or reviewed accordingly. This meant the registered manager did not have effective processes in place to monitor for any themes, trends and identify areas for learning. The registered manager did not demonstrate that the duty of candour was followed when completing safeguarding investigations. People and their relatives were not always kept informed or provided with apologies and updates in both written and verbal formats.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care and to ensure best possible outcomes for people, whilst mitigating the risk of harm. We identified in some people’s daily notes they received support from other healthcare professionals including district nurses, occupational therapists, mental health support workers and community nurses. However, the registered manager did not always ensure there were effective pathways in place to communicate effectively with these partnership agencies to ensure people’s care was delivered consistently. For example, one person had an assessment due with an occupational therapist for a hoist. The registered manager did not follow this assessment up. It was unclear what the outcome was and if this person was receiving safe and effective care to ensure safe transfers. Another person was supported by a mental health worker and had an action plan in place how best to support them. We asked the registered manager if they worked with this partnership agency to ensure their staff were aware of this action plan. However, the registered manager confirmed there was no communication between the two services. Therefore, there was a lack of continuity of care in how to best support the person and their individual needs. For another person, we identified they were receiving support from district nurses for their skincare. However, the staff were communicating to other health system partners through people rather than having direct links with partners. This did not ensure the service was working well with people and health system partners to establish and maintain safe systems of care. This also did not always ensure people received continuity of care, as the specialist care this person was receiving was not communicated effectively between the services.

The provider did not ensure there was a system in place to protect people from abuse and improper treatment. The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. We found incidents where safeguarding alerts relating to allegation of abuse, neglect or acts of omission were not raised to ensure they were investigated properly. Some concerns had been reported to the registered manager however there was no evidence these were referred to the local authority or investigated. By failing to inform the relevant authorities of the allegations of abuse, this placed people at risk of ongoing harm or abuse. The provider did not ensure there was effective oversight of safeguarding people from the risk of avoidable harm and abuse. Staff told us they would escalate safeguarding concerns to their seniors. However, staff were not aware of external organisations which could be contacted with safeguarding concerns to ensure people were not at risk of harm or abuse, and to ensure people were protected. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. There was no one who needed to have any restrictions in place.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The provider did not demonstrate they reviewed and reassessed people’s risks to ensure people were consistently protected from avoidable harm. Risk assessments did not always include enough information about how identified risks were to be managed or mitigated to ensure people’s safety. We reviewed 5 people’s care records including their care plans, risk assessments and daily notes. Risk assessments were not always in place for people to ensure effective risk mitigation. For example, one person did not have a risk assessment in place for their bed rails. It was unclear what guidance staff used to safely carry out personal care for this person in their bed, whilst mitigating the risk of avoidable harm. Another person had a risk assessment for bed rails. However, both people were not regularly checked to ensure staff provided safe care while using bed rails. A third person had diabetes, and although this person’s care plan stated they managed this themselves, there was no risk assessment or clear guidance to inform staff how to support this person if and when they had hypoglycaemic or hyperglycaemic episodes. This meant the registered manager did not ensure there was clear risk mitigation and support guidance for staff so the person not at risk of harm.Staff also told us they were “pretty sure there are risk assessments” available on provider’s care management app. The provider did not evidence there was oversight of ensuring all staff regularly referred to people’s risk assessments and care plans before providing care and treatment to ensure people were cared for in a safe and effective way.

The provider did not always detect and control potential risks in the care environment. Although people agreed staff supported them in their homes to keep safe including use of equipment as needed. However, the provider did not always make sure equipment, facilities and technology supported the delivery of safe care. We reviewed people’s daily notes and noted people’s care plans and risk assessments were not always reflective of people’s individual needs and how to support them in a safe and effective way. For example, one person’s care plan and risk assessment stated they could transfer themselves, however we identified in this person’s daily notes staff were moving the person. We asked the registered manager for clarification around this person’s moving and handling. The registered manager confirmed, “[Staff] do sometimes have to when [person] needs it”. This person’s care plan and risk assessments were not up to date to reflect information regarding safe transfers. We spoke to people and their relatives for feedback about the service, and how staff supported people to maintain a safe environment. Some people told us about incidents that were not recorded in the provider’s incident log. For example, one person told us how brakes were not properly applied on their equipment, and this created a risk of avoidable harm or injury when transferring. For another person, we found their fire risk assessment noted the established fire exits of their home. This person’s personal safety risk assessment noted, “Carers to make sure front and back door is locked after every visit”. It was not clear this person could safely escape in risk of fire or emergency. However, the registered manager could not demonstrate they reviewed and discussed any risks and mitigation with staff relating to people’s homes and equipment safety.

The provider did not make sure there were enough qualified, skilled and experienced staff to meet the complex and diverse needs of people and to ensure their safety and welfare. They did not work together well to provide safe care that met people’s individual needs. The registered manager did not make sure staff received effective and regular support, supervision and development. We confirmed with staff they did not receive training which would enable them to meet people’s needs. This included when people were living with conditions such as diabetes, dementia, mental health, catheter care, skin integrity, falls. We identified through people’s daily notes staff were training each other how to complete certain specialist tasks such as catheter care, dressings, and nebulisers. There was no evidence to show staff were assessed as competent in these areas; staff were not trained to be assessors in these tasks. The registered manager did not ensure there was a safe and effective process in place to complete these tasks without the risk of harm to people. Staff did not have competency checks completed for medicine management and moving and handling. The registered manager did not evidence there was an induction process and supporting policy in place. The provider did not have a policy regarding clear and defined process for appropriate completion of the care certificate including observations and assessing staff’s knowledge for each standard. People and their relatives told us new staff would complete shadowing. However, they felt this shadowing period needed to be longer. People told us, “It has been ongoing learning for both of us”. Mostly people and relatives were positive about the staff skills and support they provided.

People and relatives told us although their care calls were never cancelled, they were not always informed what time staff would come to attend their care calls. This was at times impacted by the number of available staff working on the day. Staff also told us about the difficulty of the travel time between care calls, and how being a small team meant it was difficult to cover care calls when short staffed. One person told us how they did not always have the required number of staff to complete the care calls as per their assessed individual needs. The registered manager did not evidence they had effective system to ensure there were appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that met their needs. We found staff did not have spot checks completed at regular intervals. The registered manager did not record information when managing staff performance or when staff were involved in incidents or complaints raised.

The registered manager did not operate effective and robust recruitment and selection procedures to ensure they employed suitable staff. We found discrepancies with gathering information of full employment history and unexplained gaps, fitness of the staff, evidence from previous employments related to health and social care regarding staff conduct and verifying the reasons for leaving. We found necessary Disclosure and Barring Service (DBS) checks were not always completed prior to staff commencing work at the service. Failing to obtain all the required recruitment information before allowing staff to work, placed people at risk of receiving care from unsuitable staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.The registered manager told us staff used personal protective equipment (PPE) and handwashing to protect, prevent and control infection to people. Staff told us they knew how to access PPE and would always use this when providing care for people using the service. We received mixed feedback from people and their relatives about infection, prevention and control. Some people told us, “There are times when gloves aren’t worn, some carers for some reason don’t wear gloves.” A relative told us, “99% of the time I see them wearing gloves”, and another person told us “Yes, they do wear gloves and aprons. But I haven't seen them wash their hands I can only assume they do.” The registered manager did not demonstrate they had consistent and regular monitoring of staff’s practices in infection prevention and control. Not all staff had completed their infection prevention and control training to ensure they understood and could manage the risk of harm to people. The provider did not always ensure there was effective oversight and management of this prior to staff providing care for people.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We reviewed people’s medicine administration records (MAR) and ‘when required’ medicine (PRN) protocols. PRN protocols lacked detail to guide staff how to safely and effectively administer people’s medicine. For example, one person’s care plan stated, “Carers to administer inhalers when required.” There was no clear information recorded how to manage this task safely. This person also used a nebuliser, however there was a lack of detail provided on their MAR chart how to support this person safely. We identified for some people medicine was not always administered. For example, one person’s weekly pain patch was not administered at all on one occasion due to the medicines not being available. This meant the person missed a weekly dose of this medicine. There was no body map to support staff to ensure the patch was correctly alternated or applied in the correct area of the body. There was no clear evidence how this error was managed. We also noted for another person they refused their blood thinning medicine for 3 consecutive days. This person’s care plan stated to “observe the medicine being taken” whilst the risk assessment did not state this was necessary. The care plan noted staff should “document if client has refused to take the medicine”. There was no clear information on how to seek clinical advice and none had been sought, putting the person at risk. The person’s daily notes did not demonstrate such observations were completed and recorded. This meant due to inconsistencies, there was a risk that medicines would not be administered safely in line with their needs. The provider did not evidence there was a policy in place to ensure people’s medicine was managed safely, and administration of people’s medicine was complete in a safe and effective way. This also did not ensure staff had clear guidance how or when to escalate concerns to ensure people were not at risk of harm. We also noted people’s medicine was not always administered as per prescribed at the correct time. For example, during our visit we found one person’s MAR chart was not signed at the time their medicine should have been administered during the care call at midday. We found later the staff signed it to note it was given at midday. We raised this with the registered manager to address it with staff. Some daily medicines were not given however it was not clear how this was identified and clarified with staff. Staff did not always record the reason why medicine was missed.