RSBC Care 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.

The provider was in breach of legal regulation in relation to the way people’s medicines were managed safely and how risks to people were managed.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff raised concerns about safety but the provider did not always formally investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Risks relating to the governance of the service were not always understood and were overlooked which had the potential to place people at risk of harm.

Incidents, accidents and complaints were not always documented which meant the provider could not be assured they had identified patterns, learnt where things went wrong and taken appropriate action to mitigate risk to people. For example, people told us there had been isolated missed calls they had reported but there was no record of this.

People and staff were encouraged to raise concerns and were confident they would not be treated negatively if they did so. One relative told us they had raised a concern about a member of staff which may have been a conflict of interests with the directors, but this was treated professionally and responded to immediately.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not always complete fully documented assessments following people’s discharge from hospital. Whilst they used assessments completed by hospital staff to determine people’s needs, assessments completed by the provider were not always documented. This meant the provider could not be assured all information was up to date when people returned home. We raised this with the provider and they assured us they would complete their own documented assessments for all people going forward.

The provider did not always ensure they received relevant information from healthcare partners to ensure people received the care they needed. For example, where one person had been reassessed by Speech and Language Therapists (SALT) and relatives had informed the provider their assessed diet had changed, the provider did not follow this up with SALT to confirm this. This person did not come to harm as the information provided was accurate but the provider’s failure to ensure they liaised with SALT to ensure they had the correct documentation placed them at risk of harm.

Processes in place were not always aligned to ensure risks to people across their care journeys were monitored and managed safely. Policies in place were outdated and had not been reviewed and therefore were not always followed to maintain people’s safety. For example, whilst complaints and concerns were addressed informally, the complaints policy was not followed.

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 dd not always concentrate on sharing concerns quickly and appropriately to protect people from the risk of abuse, avoidable harm and neglect.

The provider was not always aware of when to share safeguarding concerns with partners to keep people safe. For example, one relative told us there had been an occasion where a staff member gave their relative food that was not in line with their assessed needs which may have placed them at risk of harm. The relative told us this had been an isolated concern and there had been no repeat of this but no safeguarding referral had been made to the local authority and no CQC notification had been submitted.

A safeguarding policy was in place, but it had not been reviewed since 2002 and did not contain all the relevant information staff required to raise a safeguarding concern. Despite this, directors and staff understood what constituted a safeguarding concern and they were able to tell us when they would share these concerns with the local authority. Although action was taken internally to address safeguarding concerns, we found no evidence of any safeguarding referrals submitted to the local authority.

People were supported by staff who were committed to keeping them safe and who took immediate action to maintain their safety if concerns arose. For example, where one person was not at home for the care call and was potentially at risk of harm, carers reported it but also took steps to locate the person.

People were supported by staff who understood their rights under the Mental Capacity Act 2005 and encouraged them to make informed decisions where they were able to.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff raised concerns about safety but the provider did not always formally investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Risks relating to the governance of the service were not always understood and were overlooked which had the potential to place people at risk of harm.

Incidents, accidents and complaints were not always documented which meant the provider could not be assured they had identified patterns, learnt where things went wrong and taken appropriate action to mitigate risk to people. For example, people told us there had been isolated missed calls they had reported but there was no record of this.

People and staff were encouraged to raise concerns and were confident they would not be treated negatively if they did so. One relative told us they had raised a concern about a member of staff which may have been a conflict of interests with the directors, but this was treated professionally and responded to immediately.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Relatives told us staff supported people to ensure their home was free from any hazards. Hazard risk assessments were in place to ensure any environmental risks in people’s home were known and managed safely. Where there were risks such as smoking and fire risks, these had been identified and staff were guided how to reduce risk to people in their homes.

The provider did not always make sure staff were recruited safely. They did not always make sure staff received effective support, training and development. They did not always work together well to provide safe care that met people’s individual needs.

Recruitment documentation was not always fully completed. For example, some references were provided from employers staff had not included in their past employment history and there were some discrepancies with people’s start dates and dates of Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. This meant the provider could not always be assured staff were recruited safely.

Where staff had undertaken training at previous or second employers, training was not always run out by the provider. One staff member told us, “I am a part timestaff member at RSBC so I have training from mymain job and I submit them to RSBC.” The provider confirmed staff provided them with copies of their training certificates to confirm they had completed it. This meant they could not be assured training was adequate for their staff to enable them to meet people’s needs safely. Whilst this was a risk, people and relatives told us staff were well trained and competent to meet their needs safely. One person told us, “The staff are trained well to do what they do”.

People told us there were sufficient staff to meet their needs and people did not feel rushed when staff were supporting them with care. People told us staff were knowledgeable and provided them with good quality care that met their needs.

Staff told us they had supervisions every six months and also received additional guidance and informal supervisions from the provider when required.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

An infection control policy was in place specifically relevant to domiciliary care settings. However, this had not been reviewed since 2022 so the provider could not be assured this was up to date.

Staff were provided with personal protective equipment (PPE) in line with current guidance in order to reduce the risk of spread of infection.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff raised concerns about safety but the provider did not always formally investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Risks relating to the governance of the service were not always understood and were overlooked which had the potential to place people at risk of harm.

Incidents, accidents and complaints were not always documented which meant the provider could not be assured they had identified patterns, learnt where things went wrong and taken appropriate action to mitigate risk to people. For example, people told us there had been isolated missed calls they had reported but there was no record of this.

People and staff were encouraged to raise concerns and were confident they would not be treated negatively if they did so. One relative told us they had raised a concern about a member of staff which may have been a conflict of interests with the directors, but this was treated professionally and responded to immediately.