Archived: Qualified Care Ltd

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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 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 safe care and treatment, staffing and safeguarding service users from abuse and improper treatment.

This service scored 31 (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. Where incidents took place, the provider had failed to analyse them or take learning to prevent the incident from reoccurring. For a person who had regularly fallen, incident reports did not contain any detail on potential causes of the falls, or any steps the provider had taken to support the persons mobility and prevent the future risk of falling. Despite these falls, the provider had failed to ensure there was adequate guidance or risk assessment in place to enable staff to support this person safely. Staff meetings and supervisions were taking place which did discuss the risks to the people being supported, but despite this the provider had failed to identify that staff lacked the training or guidance to safely support people and protect them from harm.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. Where the service started supporting new people, they failed to conduct a robust assessment of their needs which meant they were unaware of the majority of people’s health conditions and how to safely care for them. This meant the service and staff were not ensuring people transitioned to the service safely, or aware of their responsibility to work in collaboration with other health and care services where appropriate. One person was at risk of diabetes but there was no guidance at all on how this should be managed safely, when to recognise concerns or who they would refer to and at what point to ensure this person received the support they needed. Another person was at risk of falls and the manager told us, “We work with a local falls response team who can assist us if (person name) has a fall and needs support in standing.” However, there was no reference at all to this team in their care plan, meaning staff did not have any clear guidance on how to contact them when needed meaning this person risked being in an undignified and uncomfortable position for longer if they fell.

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. The service was not protecting people’s right to live in safety because they did not understand the risks to people, and staff did not have a clear understanding or information on how support people safely or support them in having the best quality of life possible. The registered manager told us, “Where people have fallen, we have been told not to report this as a safeguarding if there were no injuries.” However, they had failed to recognise that people could still be being neglected or receiving poor quality of care even this did not result in an injury, and had not notified any statutory bodies, which they are legally required to do, when people had fallen.

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. Where people had health conditions, there was no guidance or information for staff on how to help people manage these safely. For example all the people being supported were at risk of falls, but there was no guidance for staff on how to prevent people from falling or how to respond safely when people did fall. One person had recently suffered a fall who was receiving anti-clotting medicine which means a significantly increased risk of internal bleeding, yet staff did not request medical advice from 999 or 111 following the fall to ensure the persons wellbeing and to receive any necessary treatment. There was no guidance for staff explaining the risks around anti-clotting medicines. Once we raised concerns to the provider, risk assessments were put in place however these were not personalised to the people receiving care and continued to lack detail on how they would be safely supported. This included a person living with diabetes where there was no information on what their normal blood sugar levels were, or what staff should do if the person’s diabetes caused them to become unwell. We were concerned that staff would not be able to recognise symptoms or concerns or understand when they may need to request medical advice if this person’s health deteriorated.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.Although the provider could demonstrate they had assessed the environmental risks in people’s private houses both to people and staff, they had not set out clear guidance of how these risks would be safely managed. For example the risk assessment identified that stairs posed a risk to one person due to their poor mobility, but there was no information about how this would be managed. Though the provider told us they conducted spot visits of people’s houses to ensure they had an up to date picture of any risks posed to people, they could not provide any documentation evidencing this had taken place meaning we could not be assured they had an accurate overview of how safe the environments they were working in were.

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. Staff we spoke with told us they were regularly working up to 20 hours a day, often without a break and for periods of up to 10 days consecutively. One staff member told us “Working here can be extremely difficult. I am only contracted to work in the day, but I have to work throughout the night also as the people I care for need extensive support. I am often very tired and have no energy to support them. I get breaks sometimes but not every day.” The provider told us they had no systems to allow them to track the number of hours staff were working. This meant people were being exposed to an extremely high risk of harm, as staff were working unsafe hours which reduced their ability to meet people’s needs in an effective manner. Staff were not trained or knowledgeable in how to manage the health needs of the people they supported, this included around mental health conditions, and health conditions including constipation, diabetes, falls risk and promoting healthy skin. We also identified staff were administering medicines without having had any training in this area, or the provider assessing that they were safe and competent to do so. The provider did not follow safe practices to ensure fit and proper staff were employed, which included DBS (Disclosure and Barring Service) and reference checks only being completed after staff had started working for the service. Where the provider’s family members had been employed, the provider had failed to ensure interviews or recruitment processes were impartial. For instance interviews were conducted by relatives, or references provided by companies we were informed were also owned by relatives.

The provider did not always assess or manage the risk of infection. Staff had received training in infection prevention and a staff member explained to us, “Yes when doing personal care I would always wear, gloves, masks and aprons. There are always enough supplies of these for us.” However, the provider could not evidence they had undertaken any checks to confirm if staff were following appropriate protocols for preventing infections in practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We were told that staff supported 2 people to receive their medicines, but the provider had failed to ensure they received any training in how to do this and had not assessed whether staff were competent to do so. This included staff administering controlled drugs. There were significant gaps in people’s records, including days where staff had not recorded if medicine had been given or not. Where “as and when” medicine was in place, there was no guidance on when these should be given and staff had not recorded why it was being administered or whether it had been effective or not. One person had a controlled drug pain patch in place which needed to be rotated across different parts of the body to reduce the risk of serious side effects, but there was no guidance on how to manage these safely or state where on the body these patches were being applied to.