Plus Point Care 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. This is the first assessment for this 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 regulation in relation to people’s safe care and treatment including medicines administration, infection prevention and control, management of health conditions and safeguarding.

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.

Whilst the provider gave opportunity for staff to collectively learn from concerns, the provider did not always report safety events to the relevant organisations.

The provider did not always report safety events to CQC. The local authority shared a concern with CQC about an allegation of abuse they had received, which CQC had not been notified of. This meant we were not assured improvements and learning had been implemented to address risks to people’s safety.

Staff told us they received an appropriate induction and knew how to respond to concerns about people’s safety. Staff said lessons were learned when safety concerns arose, to help all staff to learn and improve their practice. Staff said this was done through updates during supervision and meetings. They said when concerns arose, they were, “Handled in an open and supportive way, focusing on learning and safety rather than blame.”

Team meeting and incident records showed when concerns were raised by people, the concerns were discussed so lessons could be learned.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Safety and continuity of care was not always a priority, and social care partners were not always provided with information needed to assess risk to people. The local authority feedback shared during this assessment showed the local authority had difficulty in understanding the risks to people being supported, as the provider was unwilling to share required information with them. This meant people were at risk of not receiving appropriate continuity of care.

Evidence requested about the contact with health professionals, along with care plans, were not provided. This meant it was not possible to be assured advice from healthcare partners had been sought and been incorporated into care plans to ensure people’s safety.

The provider did not protect people to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Whilst staff told us they had received training in safeguarding and knew how to raise concerns, evidence on the training record from the provider, showed staff had not all received safeguarding training, this included staff who were providing care on their own. This meant we were not assured care staff were equipped to identify and escalate concerns of abuse, which placed people at risk of harm.

Whilst people told us they felt safe and knew how to escalate concerns about safety. Several people, their relatives and staff, said the provider was who they would contact if they had concerns about abuse. However, this would not be reliable as we identified in the absence of the provider, there was no reliable contingency for people, their relatives, staff or stakeholders to make contact in an emergency – this included escalating safety concerns, which placed people at risk of harm.

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.

People and their relatives generally felt their care was safely delivered; however, before this assessment people were not aware of the multiple failings of the provider, as outlined in this report. Therefore, people and their relatives were unable to manage the potential risk people were exposed to.

Staff had not completed sufficient training in how to best support people who were autistic or who had a learning disability. This meant we were not assured staff knew how to meet the specific needs of all people, or support them appropriately to understand risks, and therefore determine where appropriate, what risk people individually wanted to take.

We asked for care plans and risk assessments for people but were not provided with sufficient evidence to be assured care was delivered to the expected standards of safety.

The provider detected and controlled potential risks in the care environment.

People told us they did not have any concerns about the capability of staff being able to manage risk. We did not see sufficient evidence that all types of risk had been addressed, as we were not provided with all care plans and risk assessments requested. However, we were given an additional risk assessment for falls, which included how staff should identify and mitigate environmental risk. Therefore, we had assurance safe environments were provided for people as clear recommendations were made for staff to take, to ensure people had an environment which was safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The Provider was unable to evidence call timings met people’s needs and wishes. We requested a report from the Provider, to evidence the punctuality of care staff. The provider did not provide this evidence. This meant we could not be assured if calls were completed within an acceptable window of the planned call time or the required length.

People and their relatives generally told us call times varied, for example calls were sometimes early or late. Most people said they would be notified by the office, but this was not always the case. People were mostly satisfied with the length of call time; however, this feedback was not consistent. One person said staff, “Tend to do things quickly when they think I’m not looking.”

Staff told us they had provided nutritional support via a feeding tube inserted through the abdominal wall directly into the person’s stomach. This can be used to provide essential nutrition, fluids, and medication when a person cannot swallow safely or sufficiently. The training records showed staff had not received training to complete this task. This put people who had received support in this way at risk of harm.

The provider did not assess or manage the risk of infection.

Whilst people’s feedback was generally positive about how staff prevented infections, some people had concern about adequate management of infection risks when staff prepared their meals.

Training records provided showed staff who had completed personal care tasks had not all received training in infection prevention and control, or hand hygiene. This included staff who had supported people without supervision of other members of staff. We were therefore not assured staff would have the skill and knowledge to reduce the risk of harm from infection for people they supported.

A staff member told us there was no assessment of staff ability to complete personal care tasks in a way that reduced the risk of infection to people, which increased people’s risk of harm.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicine had been given by a member of staff who had been assessed by the provider. The staff member had been found to lack all the necessary skills. The staff member continued to give medicine without supervision, and they had not received additional training and further assessment before we identified this concern to the provider. This placed people at risk of receiving medicine incorrectly.

The provider had also failed to assess if staff were competent in giving medicines by different routes – for example eye-drops or by applying a ‘patch’ to the skin, which releases medicines slowly. This meant people may have received medicine in a way staff were not skilled to do, which put people at risk of harm

The staff training record showed staff who had given medicine to people had not completed training in doing this. This lack of training increased the risk to people who were supported with medicines by Plus Point Care Ltd.