Dedicated Care East Anglia 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and safeguarding people from abuse.

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.

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 learnt to continually identify and embed good practice. We identified 2 incidents that had occurred in the service and both incidents failed to ensure appropriate action was taken. On occasions medical advice was not routinely sought where required.

We found the service's monthly analysis of accident and incidents did not reflect all accident and incidents recorded therefore, they could not be analysed to identify accurate trends and themes. Furthermore, the service could not be assured appropriate action had been taken for all incidents. One of these was a fractured wrist.

There was no evidence of national safety alerts being reviewed and shared with the workforce this put people at an increased risk of harm by not being aware of any medical or product recalls.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. We reviewed the service's pre-assessment process, and it was not robust. It did not ask questions around known risks and where risks were disclosed, these were not consistently explored. Assessments did not always record the outcome of the pre-admission assessments and lacked the details in who attended the pre-admission assessment and how the information was obtained. For example, through phone calls or face to face. Personal details were missing and past medical history was not always recorded.

We received mixed feedback from healthcare professionals on referrals being submitted. One healthcare professional told us. “I do believe they make appropriate and prompt referrals and are persistent in chasing them up in most cases. I have one example of a case where I am dissatisfied by the level of active problem solving but I think this this due to lesser experienced staffing team.”

Another healthcare professional told us “In the case of [service], there have been occasions when requests for advice or liaison with relevant services were raised at very short notice. This can present challenges, particularly when safety equipment is required urgently and cannot be sourced within the available timeframe.”

The provider told us they would review their pre-admission process to ensure they recorded all information received to evidence a robust assessment is conducted.

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 identified a safeguarding concern had not been referred to the local authority safeguarding team. That involved a fractured wrist to a person.

Staff had attended safeguarding training and appeared to have knowledge around safeguarding concerns but failed to raise them. The provider’s safeguarding policy was not robust and was not embedded within the work force.

The provider told us they were informed, by the local authority, they were submitting too many safeguarding referrals. They provided us with evidence of the information the local authority provided, on what did and did not meet the criteria for a safeguarding referral. On review of this information incidents that met the criteria were still not being reported.

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. We found a person’s care plan lacked in detail of a significant historical incident that had occurred to them and put them at risk of harm. The care plan was vague and recorded that the person’s life was in danger following an incident, however, they did not provide information for staff on what that incident was to be assured how they appropriately managed the risk.

Due to the incident, they had a fire risk assessment in place that stated the individual was not to use any flammable creams or gels and emollients. We found the individual was using an emollient and a gel that was flammable. Staff had failed to identify this and evidence their care plan and risk assessment was not being followed. This put people at an increased risk of harm We informed the management team when we identified the concern and raised a safeguarding referral. The Provider confirmed they would review the care plan immediately and work with staff around care planning.

The provider did not always detect and control potential risks in the care environment. We found environmental risk assessments were not conducted thoroughly of people’s homes and when accessing the community, so the provider could not be assured risks were identified and mitigated where appropriate. However, the service ensured equipment, facilities and technology supported the delivery of safe care.

The provider did not make sure staff were qualified, skilled and experienced. They did not always make sure staff received effective support and supervision. The staff did not work together well to provide safe care that met people’s individual needs. Care plans and risk assessments were not routinely followed. We raised concerns with the provider over the competency of staff and their conduct to incident management and they carried out competency assessments on all staff.

We had concerns over some of the competency questions and found they were not robust and did not consistently advise staff on appropriate action to take. They were conducted as a questionnaire and one of the questions asked staff what they should do if they had a concern around another staff member not following a person’s risk assessment. The answer was to challenge the practice and report it if necessary. Failing to follow an individual’s care plan and risk assessment should always be reported.

We found there was a lack of supervisions conducted in the service. On review of the service’s supervision matrix, it appeared staff only had 2 supervisions a year and these appeared pre-booked. No supervisions were conducted following incidents and appeared no one had had more than 2 to support them within their role. The supervisions were ineffective and task focused. Staff lacked in the skills and knowledge needed to effectively support people safely. Directly exposing people to unmanaged risks and care that fails to meet their individual needs.

Only a small number of staff had completed palliative and end of life training.

The provider did not always assess or manage the risk of infection. The provider had infection control audits that were conducted within the service, they were not robust and they failed to assess the effectiveness of hand hygiene measures. They did not evidence personal protective equipment (PPE) was available where required and could not evidence staff have applied and removed their PPE as appropriate. The provider told us the staff were trained in hand hygiene and applying and removing PPE. However, they could not evidence this was routinely monitored to ensure this taught practice was embedded.

However, the provider had an infection prevention and control policy in place that aligned with best practice guidance and staff had completed infection, prevention control training.

The provider did not always ensure that medicines and treatments were safe and that they met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We identified a person that took an anticoagulant medication, which thins the blood, had a risk assessment in place. However, it failed to identify all the risks of taking a blood thinning medication and the action staff should take if the individual was to have any head injury or fall.

However, where people took their medication independently, these were risk assessed. Where people had prescribed creams body maps and medication assessment records (MARs) recorded these clearly for staff.