Archived: Santos Care 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

Our rating for this key question has remained inadequate. The service was not safe. We identified a continued breach of the legal regulations. Risks to people’s safety were not always safely managed. Unsafe staff practices had not been identified by the management team which placed people at risk of harm. The management team failed to provide accurate consistent information to staff about the use of emergency medicines and information about people’s mobility needs and risks were not consistently documented. This placed people at risk of harm. However, improvements had been made to ensure staff were now safely recruited and some learning had taken place following incidents and events.

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.

Feedback from people about learning from incidents and events was mixed. Some people felt the management team took appropriate action in response to incidents and events and reviewed people’s care needs. Others felt this had not been done and people had been left receiving unsafe care.

Staff told us learning from incidents and events was shared with them in team meetings. Leaders told us they reviewed accidents and incidents and shared messaging with staff about how to protect people from future harm.

Processes used to contribute to a positive learning culture were in place but were not always effective. Audits of incidents were not always accurate which meant actions were not completed in a timely way. Leaders had begun to establish systems to share learning from incidents, using staff meetings to communicate changes.

When safety concerns were raised with leaders at feedback, effective action was not always taken which meant a learning culture was not adopted and people continued to be exposed to a significant risk of harm.

People told us their needs were not always assessed by the provider prior to receiving care. However, they told us care plans were implemented once in receipt of care.

Leaders told us they had systems in place to review referrals and assess people’s needs in order to plan their care. Staff told us they had access to this information prior to providing care. However, staff we spoke with were not always able to demonstrate that they aware of the wider risks associated with people’s health and care needs.

Local partner agencies told us they did not have contractual arrangements in place with the organisation. We reviewed information which reflected changes had been made following reviews by partner agencies in relation to people’s care needs.

Processes were in place to assess people’s care needs. However, these were not always effective which resulted in risks not being effectively managed. We found risks in relation to falls, mobility, personal care and medicines were not appropriately assessed or planned for. This placed people at risk of harm.

We received mixed views about safety. Some people told us they felt safe when receiving care where others expressed concerns about unsafe staff practices.

Staff had some knowledge of how to recognise signs of potential abuse or harm. They told us they would share any concerns with the management team.

Leaders told us they reported safeguarding concerns and understood their responsibility to follow local safeguarding processes.

Although processes were in place to ensure information of concern was shared appropriately, these were not always effective in keeping people safe. For example, we found people had been in receipt of unsafe care, but this had not been reported by staff or identified by the management team. In addition, information provided to staff about how people’s care should be managed was not always up to date and therefore placed people at risk of harm.

Most of the feedback from people and relatives reflected they felt they received safe care and risks were safely managed. However, a relative shared with us some concerns about unsafe practices carried out by staff when supporting a person with personal care.

Staff were not consistently aware of risks to people’s safety. Staff knowledge about how to manage people’s risks was varied. Some staff demonstrated a good understanding in this area while others seemed unclear about how risks should be safely managed.

Leaders told us they assessed people’s risks when they started providing care and then annually unless their needs changed.

Guidance available for staff about risks to people’s safety were not always clearly recorded and for some people was inconsistent. For example, a person had recently experienced a number of falls, but information in their care plan had not been fully updated to reflect the changes in their care needs. Daily notes completed by staff reflected that the person’s bed was lowered and a crash mat was put in place next to the person’s bed, however there was no reference to this in the person’s care plan.

We received concerning feedback about how a person’s home environment was managed. This included concern about how equipment used to support the persons mobility was used. Other people spoke more positively and expressed no concerns about how staff supported them in their home environment.

Staff told us they had received training to enable them to safely use equipment, such as hoists used to support people’s mobility.

Leaders shared how they arranged face to face training for staff to ensure they had the required skills to support people.

Risk assessments relating to the environment and equipment used were not always in place and when they were they were not always current and therefore did not consistently provide accurate information for staff to follow about how to support people safely. Effective systems were not in place to check people’s care environments and to monitor that staff were using equipment safely.

We received mixed feedback from people and relatives about the consistency of staff. One person told us, “We have a small set of regular carers, a group of about 5 or 6 that we know well.” Another person told us their experience with staff had improved, commenting, “Before I had carers who didn’t talk to me but they gave me different carers…they are new and they listen to me.”

However, a third person expressed concerns about the inconsistency of carers and their approach. They told us, “[Person] has the same carer for weekday visits and different carers at the weekend and we are having difficulties with this. One carer is not very communicative at all and another one is heavy handed, [person] is very frail."

Staff told us they felt supported by the management team. One staff member said, “I had a 3 day induction and then training. We have monthly staff meetings where we can discuss issues or ask for extra training.”

Leaders told us they had made improvements to staffing allocations and training. They told us staff now received training in relation to people’s specific health conditions and emergency medical requirements.

Improvements had been made to recruitment processes and records we reviewed reflected appropriate checks had now been carried out on staff to ensure they were safe to work with people. Improvements had also been made to the consistency of staff teams, meaning people generally received support from staff who knew them.

Systems used for the monitoring of call times were used by the management team on a daily basis and reflected the majority of people’s calls were on time.

People told us staff protected them from the risk of cross infection by using Personal Protective Equipment (PPE). One relative said, “All good, they do wear masks all the time and gloves and aprons. They come in wearing masks and then they put on gloves and aprons and they put it all in the bin as they leave."

Staff told us they had received training in infection control. They told us this included hand washing techniques and the safe disposal of Personal Protective Equipment (PPE). Staff also reported that the management team carried out spot checks to ensure they were using PPE in accordance with guidance.

Leaders told us they kept adequate stocks of PPE and ensured staff carried supplies with them. They confirmed infection control was reviewed as part of regular spot checks.

Processes were in place to support staff to reduce the risk of cross infection.

Most of the people we spoke with administered their own medicines. However, a relative told us their family member’s needs in relation to medicines were now included in their care plan.

Staff told us that although most people managed their own medicines, they had received training to administer medicines if required.

Leaders told us all staff had received training in the administration of medicines. The nominated individual told us they assessed the competency of staff to ensure they were safe to support people with their medicines.

Processes established to ensure the safe management of medicines were not effective. Where people used ‘as required’ medicines, guidance for the use of these was not consistently available. Guidance for staff to follow around the use of emergency rescue medicines was inconsistent, which could result in significant harm to people.