Agathah Limited

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 rated this key question requires improvement.At thisassessmentthe rating haschanged to 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; the ways people’s medicines were managed safely and safe,safeguardingand effective staffing.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events.Lessons were not always learnt to continuallyidentifyand embed good practice. Systems were in place to ensure accidents and incidents were analysed and trends and patternsidentifiedto mitigate risks. However, these systems had not been tested as the provider told us there had been no incidents to report and no areas which instigated the lessons learnt protocol. At the last inspection, the provider had been in breach of legal requirements. At this assessment, we found that there had been insufficient improvement, and the provider continued to be in breach of regulations. Thisdemonstratedthat lessons were not always learned, and that systems and processes designed toidentify,monitorand embed good practice were not consistently effective.

The provider did not always work well with people and healthcare partners toestablishand maintain safe systems of care. They did not always manage ormonitorpeople’s safety. They did not always make sure there was continuity of care, including when people moved between different services.One person’shealth condition was not clearly recorded in their care planning documents and informationregardingprofessionals involved in thisperson’scare, were not recorded.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider’s safeguarding policy and procedure did not containappropriate informationto enable staff to report concerns without delay. There were no contact details available for the local safeguarding team. The policyidentifiedspecific responsibilities for the safeguarding lead within the company; however, no named safeguarding lead wasidentified.Mental capacity assessments had they been completed in line with the Mental Capacity Act (MCA) 2005.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe,supportiveand enabled people to do the things that mattered to them. Since our lastassessmentthe provider had focused on improving care plans and risk assessments and we found some improvement. However,notall risks associated with people's needs were managed to keep people safe. For example, 1 person’s care records lacked detailed information to ensure staff were fully aware of risks and in relation to a health conditionwhich meant staff did not have clear guidance on how to manage those risks safely. The provider told us they wouldtake action to ensurethe documentation was updated.

Theprovider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental risk assessments were carried out prior to carecommencingand at regular intervals. These considered risks in relation to things such as lighting,petsand appliances.

The provider did not make sure there were enough qualified,skilledand experienced staff. They did not always make sure staff received effective support,supervisionand development. They did not work together well to provide safe care that met people’s individual needs.The providerhad a recruitment policy but did not follow this to ensure staff were safely recruited. Application forms were not always in place and where they were, they were not completed fully, and no full employment listed. Pre-employment checks had not always been carried out to ensure staff were suitable to work with vulnerable people. For example, there was minimal evidence reference requests and Disclosure and BarringService (DBS) checks had been carried out. There was no evidence of staff interviews and no documents in place to ensure missed information on application forms had been explored.The provider could not evidence staff had received ongoing training to carry out their roles safely. We saw staff covered 21 mandatory training topics in 1 day, including practical first aid and manual handling. The provider did not carry out any competency or knowledge checks to ensure staff had understood and learnt from the training. Since our last assessment we saw some staff supervision sessions had taken place, however, there was no direct, consistent support for the registered manager.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns withappropriate agenciespromptly. The provider had an infection control policy and procedure which guided staff to reduce the risk and spread of infection. Staff had access to personal protective equipment (PPE) and used this as and whenrequired.

The provider did not make sure that medicines and treatments were safe and met people’s needs,capacitiesand preferences. People were not involved in planning.The provider had failed to ensure robust systems were in place to ensure people received their medicines as prescribed. People had medication administration records [MAR’s] in place where staff recorded medicines they had administered. However,these lacked detail. For example, 1 person’s MAR did notalways detailinformation of how often medicines were to be taken and some doses were not signed for. The provider’s medication policyfor ‘as required and variable dose medication’stated, ‘AgathahLimitedunderstands that there must be clear and precise instructions whenserviceusers require PRN(as required)medication.’However, we found there were no protocols in place for people’s prescribed medicines on an ‘as and when’ required basis. This meant staff had no clear guidance to follow to ensure people received their medicine when they needed it.The policy alsostated, ‘When variable dose medication is prescribed (for example, give1or2tablets) it is essential that the actual dose given is recorded. This should bedone on the MAR chart or, where considered necessaryfor clarity, a supplementary recording sheet could be used.’ We found staff had not recorded the dose give when people were prescribed a variable dose.Therefore, the provider could not always evidence thattheir policy had been followed or whethermedicines had been administered as prescribed.Staff had not received training in the administration ofmedicines,and their competencies had not been assessed.This put people at risk of unsafe care.