Community Care Direct Ltd

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 did not rate this key question because we did not look at the quality statements in this domain. At this assessment we have looked at all of the quality statements and this key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. The provider did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Incidents and accidents were not routinely analysed for patterns and trends. There were some missed opportunities to lower the risk of harm for a person because an unexplained injury had not been recorded in the incident log. We raised this with the provider during feedback who agreed to audit staff care notes to ensure no further incidents had been overlooked.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were examples of staff sharing information safely with hospitals and hospices when needed to ensure smooth transitions.

The provider worked well with people and healthcare partners around safety. They did mostly concentrate on improving people’s lives and protecting their right to live in safety. However, the provider did not always share concerns quickly and appropriately. One person had an unexplained injury which was not recorded in the incident log or reported appropriately. We escalated this to the provider who confirmed they would raise awareness of the need to report and record these events promptly and would discuss with staff at team meetings.

The provider had positive relationships with people; however, more work was needed to understand and manage risks. Staff knew people, and provided care to meet people’s needs. However, records and documentation relating to risk management did not evidence this. For example, 1 person who was at risk of choking did not have a choking risk assessment in place. They did have a risk assessment for management of aspiration. The mitigation recorded for this was to refer to Speech and Language Therapist (SALT) guidance. However, there was no SALT guidance in this person’s risk assessment or care plan to refer to. Another person was at risk of falls. After they had sustained a fall, the incident log said the care plan was updated to reflect the person’s fall, although we found this action had not been carried out. All of the risk assessments we viewed were not dated, so we could not tell if they were recently assessed risks or if risks had been regularly updated.

There were no environmental risk assessments in place for any of the care packages. This meant risks to staff and people, such as when highly flammable creams were being used or oxygen, were not assessed. We shared our concerns with the provider, and they immediately added new environmental risk assessments to their records.

The provider was accepting of our feedback and has since assured us all risk assessments will be reviewed and where necessary, added to their records.

The provider did not always detect and control potential risks in living environments the staff were working in. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, risk assessments on the environment were not carried out.

While the provider ensured staffing levels were adequate, they lacked proper systems for staff supervision and development. Staff did tell us however they could approach the provider for support whenever they needed. Supervisions were outdated and not formally documented, and this concern was raised during the assessment. Staff were recruited and selected safely.

The provider assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly. There was an infection control policy and procedure in place and staff told us they had a good supply of PPE.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medication errors led to learning, and appropriate PRN (medicines taken as required) protocols were in place where necessary.