Michdeede 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of the following legal regulations: safe care and treatment, staffing and fit and proper persons employed.

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 have a positive learning culture and systems to identify and learn from incidents were ineffective.

Systems to record and learn from accidents, incidents and concerns were not embedded, including where concerns about medicines had been raised. There was no evidence to demonstrate how analysis or shared learning would take place following incidents or complaints, which increased the risk of repeat harm.

Systems for managing referrals and transitions were inconsistent and did not always ensure safe care. They did not always manage or monitor people’s safety. Leaders described processes to assess needs before accepting people, including ensuring appropriate staffing and gathering information about risks. However, risk assessments were brief or did not cover all areas of required care and key documentation. For example, moving and handling risk assessments was missing. Care plans and risk assessments did not always provide accurate or accessible guidance for staff, limiting safe continuity of care. This meant staff did not always have the information they needed to support safe transitions and continuity of care.

People were not fully protected from the risk of abuse because safeguarding systems were not effectively implemented. Staff had not received any safeguarding training since joining the provider. Staff were able to describe some signs of abuse and part of the reporting process, including escalating concerns to the local authority or police. However, staff required prompting about safeguarding responsibilities and told us they had not been given access to safeguarding or whistleblowing policies. One staff member said they did not know where the safeguarding policy was. Relatives had not been informed how to raise safeguarding concerns, increasing the risk that abuse may not be appropriately identified or reported.

People were not consistently involved in managing risks to their safety. There was no evidence people or all relatives were actively involved in risk management or reviews of care. One relative told us they had been asked some questions about risk. Risk assessments and care plans often lacked clear and accurate guidance and were not always available in people’s homes, meaning staff relied on informal knowledge rather than documented plans. Although staff could describe supporting people with mobility or manual handling, this was not always supported by clear, reviewed risk documentation.

In one person’s risk assessment reference was made to a call bell to be within reach for the person, which the relative confirmed never existed. This meant we were not assured people were involved in managing risk accurately.

A risk assessment advised turning someone at risk of pressure sores every 2-4 hours and that this information was in the care plan. When we looked at the care plan the information was not there. Staff did not demonstrate they were aware of this risk either.

Where equipment was used there was no moving and handling risk assessment on how staff were to use it safely, for example, staff told us a hoist was used to support people with transfers. Whilst staff were able to explain how they used the hoist, they had no access to a care plan with guidance and the care plan we viewed made no reference to this equipment. The care plan for moving and mobility assistance was vague and stated, “appropriate moving and handling equipment should be used in accordance with the moving and handling risk assessment and care plan”. The issues found above and lack of information put people at risk of avoidable harm.

There were breaches relating to safe care and treatment.

People were supported in environments that were clean and well maintained, but systems to ensure safety were not robust for the use of equipment. Staff told us they used equipment for moving and handling and there was no information to show the equipment was checked for safety before people used it. There was limited evidence of formal safety checks or environmental auditing, reducing assurance that risks were consistently identified and managed.

The provider did not make sure there were enough qualified, skilled and experienced staff.

There were significant concerns about staffing, including recruitment, training and oversight which placed people at risk of harm. Safe recruitment processes were not followed, and records did not demonstrate how decisions had been made. Staff had not received appropriate induction, training, supervision or appraisal in line with provider policy. Staff confirmed gaps in training, with one stating, “I’ve not done any training with [registered manager]” and another saying, “I need more training”. There was also a lack of supervision records and inconsistent recruitment checks, which increased risks to people’s safety. This meant staff were not suitably supported to deliver safe care. A relative questioned whether staff sent to provide care had been trained as they queried their competence and understanding.

Infection prevention and control practices were effective and helped to protect people. Relatives confirmed staff used PPE appropriately and maintained cleanliness within people’s homes. Leaders described providing PPE and maintaining hygiene standards, and staff had access to equipment needed to support safe care delivery. These arrangements supported the prevention of infection, although wider governance systems to monitor infection prevention control were not clearly evidenced.

A relative was pleased with how their family member was supported with personal care. They said, “[Person] always gets a good wash”.

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

Medicines were not managed safely. Staff administered medicines without evidence of appropriate training or competency assessments. Medicines administration records and risk assessments were not consistently available in people’s homes. Staff confirmed they did not record on a MAR, a member of staff said, “No recording of medicine on a MAR… I write in my daily notes”.

There was no evidence of medicines audits or effective provider oversight, increasing the risk of errors and unsafe practice. This placed people at risk of medicines errors and avoidable harm. We signposted the registered manager to the NICE guidelines for managing medicines in the community. After the assessment the registered manager sent a MAR to us, however, this lacked detail on how medicines were to be recorded after they had been administered.