Candlelight 747 Healthcare 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 newly registered service. 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.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. The registered manager talked about how information was communicated to staff. Audits had failed to identify some of the issues we found, for example contradictory care plans and when required medicine records, this meant learning opportunities were missed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff gave handovers to people’s other carers and family to ensure continuity of care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. At the time of the inspection there had been no safeguarding incidents. The registered manager and other staff members were able to describe what action they would take if an incident should occur.

The provider did not always work well with people to understand and manage risks. We found no evidence that people came to harm because of poor risk management. However, staff did not always provide care to meet people’s needs in a way that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were not robust, they were missing key information about how to care for people safely. One relative said, “We help [Candlelight 747 staff] integrate with our team and believe that the consistency of staff helps [person]. Communication is key and we are talking about this a lot at the moment – so everyone in [person’s] care team knows the plan and follows it accordingly.” Following the inspection the registered manager explained they were making improvements to risk management.

The provider did not always detect and control potential risks in the care environment. Records did not always support the safe use of equipment, facilities and technology to deliver care. However, relatives confirmed that staff did use people’s equipment safely. The registered manager confirmed plans were in place to improve risk management in the future.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The small team worked together well to provide care that met people’s individual needs.
Recruitment checks were in place to ensure only suitable staff were employed to work with vulnerable people. We found occasions when reasons for gaps in staff employment were not fully recorded and where there were too few references provided.
Staff had not received training on learning disabilities and autism, which is a requirement for all staff working in care. We raised this with the registered manager, and they arranged for staff to receive the training immediately. Staff had completed all other training relevant to the role including specialist training for Percutaneous Endoscopic Gastrostomy (PEG).
The registered manager accepted out findings and planned to make improvements to the recruitment process.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
People and their relatives raised no concerns regarding infection control.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines records were not always up to date meaning people were at risk of receiving incorrect medicines. Records of ‘when required’ medicines were not in line with best practice guidance. Medicines audits had taken place but had not identified the issues we found during the inspection. The registered manager acknowledged the failings and was planning to make improvements to the medicines management process as soon as possible.