Radis Community Care (Stanbridge House)

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• 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 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 service was in breach of legal regulation in relation to safe care and treatment.

This service scored 50 (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 listened to concerns about safety, but these were not always investigated and reported correctly. Lessons were not always learnt to identify and embed good practice.

Incident management, oversight and learning were limited. Some people using the service experienced behaviours that communicated an emotion or distress. These incidents were investigated however, no actions were put in place to mitigate risk. Staff told us people were not positively supported to regulate their emotions. There was no assurance that the service had learnt from these incidents. Staff told us, “I feel these things need to be dealt with better.” This meant the provider could not evidence that lessons learnt were shared with staff and improvements made to reduce the risk of reoccurrence.

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.

Critical care information was accessible to professionals when people accessed different services. However, this information did not always contain up to date relevant information that reflected people’s needs. For example, one person’s care plan was inconsistent and stated that they required insulin to manage diabetes, but also stated they no longer required insulin. This meant people were at risk of harm as professionals had incorrect information available to them.

People’s care was planned with them and their relatives. Initial assessments were carried out with people, but no evidence was available to validate this. People had care plan reviews.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The registered manager told us they monitored safeguarding by using a log. On the day of inspection, this was not up to date. We gave feedback to the provider and they took action to rectify this.

Daily notes evidenced one person experienced very low blood sugars in the evening. These daily notes had been audited however, no action had been taken to ensure that the correct professionals had been consulted, or that the care plan provided escalation information. This put the person at risk of unsafe care. Safeguarding alerts had not always been raised where necessary. The registered manager did not always understand their responsibilities to raise and investigate concerns around safeguarding. This meant people were not always protected from the risk of abuse and harm. Staff received training in safeguarding and know how to raise concerns, but notifications were not always made to CQC.

People told us, “I am very safe” and “They did a safeguarding assessment recently as I had a small fall….so the care plan was probably reviewed.”

The provider did not 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.

Systems in place to assess and monitor risk to mitigate harm were not robust. Staff did not always support people to reduce and mitigate risks. Staff did not have sufficient guidance available about how people’s medical conditions affected them and what support was required to keep them safe.

Risk assessments were not in place or did not provide enough detail for staff to ensure people received safe care and support. Moving and handling assessments did not identify their mobility needs and conflicted with other care records. Where people required support with moving and handling, there was limited guidance to ensure staff had the correct information to support people. Information around people’s mobility was conflicting, there were no falls risk assessment in place or guidance on how to support people’s mobility needs.

One person used a Continuous Positive Airway Pressure (CPAP) machine at night. A form within her notes stated staff should support the person with use and maintenance of the machine. We found no information, guidance or risk assessment in place for this. The care planning had not been updated to reflect this change, therefore staff did not have the information required to provide support relevant to the person and their needs.

We identified there were missing risk assessments and mitigation, for, diabetes, refusal of personal care, nutrition, infections, skin integrity and continence care.

Staff told us, “You never get time to read them [risk assessments]” and “I don’t know if anything gets done if there is a conflict in the care file.”

The service was a domiciliary care agency that supported people who lived in their own homes. The provider did not have responsibility for the safe maintenance of the property. However, they assessed, identified and sought to improve identified risks in the homes of people using the service. The provider made sure equipment, facilities and technology supported the delivery of safe care.

Staff were trained in Fire safety and had regular updates from the housing provider. Staff said people’s equipment was always maintained and any problems were dealt with quickly.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

One staff member’s employment reference stated there were concerns about their character and suitability for the role. There were no risk assessments or assurances to mitigate any potential risks posed to people. Another staff member’s file indicated that further investigation was needed to assess their suitability to perform a care role, but this had not been actioned.

Where concerns had been raised regarding staff conduct, the registered manager did not always document action taken, to ensure people’s concerns were investigated and appropriate remedy’s put in place. Staff said, “New carers are not allowed into certain people because they are abrupt in manner and rough with manual handling. This has been brought up with the registered manager. [It] feels like I am having to do more work and nothing gets done about it.”

However, people told us, “They are never terribly late and once they are finished, if they have time, we have a chat” and “they do everything and are never too late.”

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 infection, prevention and control training and used personal protective equipment (PPE) appropriately.

People told us, “Staff wear gloves and aprons and change them regularly and wash their hands,” and “They wear both and wash their hands when coming in and when leaving and put the old gloves in a bag and dispose of them.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. People’s medicines were not always administered and recorded safely.

People's care plans lacked relevant information about the support they required with prescribed creams. One person’s care records documented they required physical support from staff to apply their prescribed creams. However, there was no medication administration record (MAR) in place for this, and no guidance on where to administer the cream. This meant staff did not have the information required to appropriately support the person and would put the person at risk of inappropriate administration of the cream. The provider could not be assured that people had received the appropriate support to ensure their prescribed creams had been administered correctly.

Where people had ‘when required’ medicines (PRN) in place, there were no instructions to guide staff on why or when the person may require these medicines. Daily notes did not identify if these medicines had been requested by the person, and MAR charts were not always in place for PRN use. This put people at risk as staff did not have the information to ensure medicines were administered as prescribed. However, we found no-one had been harmed.

Medicines audits had not identified the concerns we found during this assessment. For example, MAR charts did not contain the name of medicines prescribed where people used Dossett boxes, (A dossett box is a medication organizer with compartments labelled by day and time (e.g., morning, noon, evening, night) to help people manage their prescriptions). Therefore, staff could not record or escalate any concerns if any medicines had been missed or refused.

Some people administered their own medicines; however, there was no record of what medicines they took in case of an emergency. Staff were not aware of any risk associated with these medicines. However, staff had their medicines competencies checked and had completed medication training.