2M Health & Home Care Services 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

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A system was in place to report, record and monitor incidents and accidents to help support people safely. Incidents and accidents were documented and referrals made to other healthcare professionals where appropriate. However, records contained a lack of information about lessons to be learnt following an incident/accident to identify if any actions could help prevent them from happening again.

Care workers told us that there were team meetings, and they had regular supervisions and spot checks with management in which accidents and incidents were discussed. One staff member said, “We have staff spot checks, about 4 times yearly.”

Most people told us they were able to speak with staff and management. They were aware of the complaints process. One relative said, “Things have improved [timings, same carers] massively over the last year, a massive improvement.”

However, this is the third consecutive inspection where the provider has failed to meet the regulations. There have been repeated breaches in relation to safe care and treatment, and good governance across all 3 inspections. This meant the provider had failed to make and sustain the necessary improvements to ensure people received good quality care.

People’s care records did not always accurately reflect their needs or provide sufficient guidance to staff to allow them to support people safely or provide accurate or up to date information if shared with other parties. New referrals were assessed face to face by the provider to ensure people’s needs could be met and information was gathered from both people and their relatives. Contradictory records in some care plans increased the risk of care pathways and transitions not being safe as the information being shared was not always accurate or up to date. However, people received support from a consistent staff team who knew them well which supported good continuity of care and reduced the impact on people.

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.

People told us they felt safe being supported by the provider. One person said, “Yes, I`m safe, I get on well with the carers, I know them, and the care is good.”

Staff confirmed they had received safeguarding training and had access to the provider’s safeguarding policy and procedure. Staff understood their roles and responsibilities to keep people safe from abuse and avoidable harm. Staff told us they felt confident the provider would act on concerns.

Safeguarding incidents had been reported to external agencies as required. However, while internal investigations were completed by the provider records failed to detail whether the incident was substantiated or not and what lessons had been learnt. This meant the provider could not be fully assured patterns and trends were identified to prevent reoccurrence and opportunities to learn were not always recognised.

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, supportive and enabled people to do the things that mattered to them. Risks to people were not always identified and risk assessments did not always contain enough detailed information for staff to know how to keep people safe.

Some people’s care plans did not include all the information staff needed to understand the persons health condition and how to identify concerns if people were unwell. For example,1 person’s care records identified they were at risk of urine infections. However, there was a lack of information about the signs this person might show if they were unwell with an infection. This meant people were at risk of staff not identifying signs of deterioration in their health condition.

We received mixed feedback from staff in relation to the management of risks. One staff member reported care plans to be “A bit basic, lacking management information on some people's conditions.” Despite the evidence above, people and relatives told us they and their loved ones were safe, and staff knew them well.

The provider did not always detect and control potential risks in the care environment. Some care records had inconsistent and conflicting information in relation to equipment people used. For example, 1 person’s needs had changed and was being cared for in bed. However, their care records guided staff to support them to transfer to their chair. This person’s care records also recorded they required the use of bed rails. However, there was no risk assessment in place of whether the use of the bed rail would prevent the person from moving freely or make the person feel restricted from moving freely, increasing the risk of injury. Staff also did not have information on how to evacuate a person who had mobility needs safely in the event of an emergency, such as fire. Whilst overall people received care from regular staff that knew them well, there was potential risk of harm if staff unfamiliar with the person’s needs were required to provide care.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. Complaints records contained concerns raised by people stating their care calls were late. One person’s complaint recorded their care call was 1 hour late, and they were not told about the delay. We identified through the provider’s electronic call monitoring records only 77% of calls were delivered within 15 minutes of the scheduled start time over the last 3 months, and of these late calls around 5% were more than 45 minutes late. The provider had a system in place to monitor call timings but failed to record all actions taken when calls were delivered late. However, the people we spoke with told us they were informed when calls were going to be late. One person said, “I know what time that they are coming, and they tell me who is coming, and they stay the full length of time and if they have finished early, they talk to me and say, ‘is there anything else that I can do?’”

Staff were recruited in a safe way. Appropriate checks were carried out before employment was offered so that as far as possible, only suitable staff with the right skills and experience were employed.

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.Staff had completed Infection prevention and control (IPC) training. Staff told us they had access to personal protective equipment (PPE) to keep themselves and people safe.The provider carried out spot checks of staff practice which included checks to make sure staff were using PPE appropriately. People and relatives confirmed staff adhered to IPC standards. One relative told us, “[Staff wear] gloves, apron which they put in dustbin bags and throw out on the way out. They also put anti-bacterial cream on when they arrive and when they leave.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not well managed. People were not always having their medicines as prescribed. This had the potential to cause them harm. For example, medicines administration records (MAR) showed 1 person did not receive their pain relief at the correct timings on 68 occasions over the previous 2 months.

Handwritten medicine records were not always countersigned by another member of staff. This meant information had not been checked to ensure it was accurate and matched the prescriber's instructions, which placed people at risk of their medicines being administered incorrectly.

Not everyone prescribed anticoagulants (medicine to help thin the blood and prevent blood clots) had a risk assessment in place to detail safe ways of working for staff.This meant there was no guidance for staff to follow if a person at risk of excessive bleeding was injured.

While there was oversight of medicines errors and administration, this failed to identify the concerns found on inspection.

Staff told us they received training, and competency checks in relation to medicines. Comments included, “We have a new system, and we log in every time, it has every medication in the system.” Despite the evidence above, people and their relatives told us they were supported with their medicines. One person said, “They give it [medicine] to me and watch while I take it, this makes sure that I have.”