1st Central 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 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 legal regulation in relation to how people’s medicines were managed, how incidents and accidents were managed and shortfalls in staff training and development.

This service scored 34 (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 proactive and positive culture of safety. Lessons were not learnt to continually identify and embed good practice.

The provider did not always investigate safety events and make required changes when peoples circumstances changed, for example we found that 1 person had fallen, whilst the incident was reported no investigation had taken place. We also found that despite the fall occurring on the 17th of February there had been no review of care plans and risk assessments of the affected person when we attended their offices on the 10th of March. Therefore, we were not assured staff providing care were aware of the persons current needs or risks and how to manage these, if these had changed.

There was no evidence of falls logs or accidents audits being completed, this did not enable the service to review themes and concerns within the provision to embed and improve good practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had a good working relationship with other healthcare partners; there was evidence of good communication between the local GP and hospice services that the provider worked closely with.

For example, a person using the service developed difficulties swallowing and taking medicines, the service promptly liaised with the GP and sourced support with medicines as well as a referral to the (Speech and Language Therapy) SALT team.

The provider did not share concerns quickly and appropriately.

The provider at the time of inspection had not submitted any statutory notifications, our inspection team asked to review their safeguarding paperwork and files but found that none were retained.

Upon closer inspection of peoples records we found instances of safeguarding concerns that had not been reported to CQC. For example, A safeguarding concern was raised by a family member of a service user regarding the treatment of pressure sores by a partner agency. The provider did not inform the CQC of this safeguarding incident, failing to meet their statutory duties.

On another occasion, a safeguarding alert was raised against the provider by a healthcare professional due to incorrect people handling by staff at the service. The Registered manager confirmed that they had investigated this incident and found that the concerns were valid at which point they held a debrief session with the staff concerned. The provider could not supply us with any investigation or outcome notes, they also failed to notify CQC of this incident.

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.

We found that peoples care plans did not consistently capture their views, for example, one care plan indicated that the individual lacked the capacity to make decisions concerning their health and well-being. It also stated no family involvement, with the hospice serving as the sole point of contact, there was no record of an advocate engagement to assist in developing this individual's care plan to ensure their views were captured.

We found that people and their families were not always involved in reviewing changing care needs. A family member of a person who uses the service told us, “We do need a care review, as I can’t go on like this, these carers are not giving the right support.”

The provider did not always detect and control potential risks in the care environment.

We found no evidence that risk assessments were in place for providing care in the environment of people’s own homes. There were no audits or monitoring in place to identify and address any concerns.

The provider was unable to supply health and safety reports, including fire safety reports for their offices. Additionally, they could not provide Display Screen Equipment (DSE) assessments for their office based staff. As a result, we are not assured that there is adequate consideration given to safe working environments for the staff employed at the service.

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.

We found that the service could not evidence supervision for any of the staff employed except for the registered manager who was supervised by an external consultant. We found concerns with the accuracy of these supervisions, for example on one supervision it is recorded by the consultant that ‘Incident and Accident Log’ was reviewed, these were not in place. Another supervision recorded that ‘Staff Supervision Records’ were reviewed; these were not in place.

The registered manager told us that staff supervisions occur every two months but claimed they were carried out informally and not recorded. This lack of structured supervision impacted the services ability to support, develop and train staff effectively.

The lack of structured staff supervisions had impacted people using the service. Feedback from relatives of those using the service included, “One time, they’ve left [their] bed rail lowered and have left the tap closed on [their] catheter, it's not a lot, but I always have to check them. [person] complains a lot to me.” And “Some carers do not know the process to open [their] bowels and clean [them]. I can’t do it, and I need their help. My [family member] comes and helps me, but the carers should be doing things properly.” Another told us, “[person] has very tender arms and legs. If the carers are not careful, it hurts [them] when they do the creams, and [they] call out. Some of the carers understand, but some of the new ones don’t. Also, getting [person] out of bed into [their] chair can be painful for [them] if they are not careful, some carers have got it, others haven’t. We’ve reported it to the manager, and the palliative care nurse has as well.” Another family member simply told us, “Some of these carers just simply don’t know what to do.”

The provider did not assess or manage the risk of infection. We found that the provider did not carry out any audits or assessments on Infection Prevention and Control (IPC) risks within the service. We did see evidence of discussions with staff on hygiene practices and the service operated a bare below the elbow policy in practice. However, evidence of these discussions was inconsistent due to the provider not keeping all records of discussions held with staff, there was also no consistent way to follow up concerns raised with staff.

The Infection Prevention and Control (IPC) training provided by the service comprised both e-learning and in-person sessions. All staff successfully completed the 30 minute in person IPC training. E -learning for IPC had been completed by 5 staff out of the 42 employed by the service at the time of the inspection. The provider told our inspection team that they supplied PPE to their workforce and staff told us that this was catered for.

This impacted some of the people who used the service, some feedback we received from persons and family who use the service included, “We have to tell them what to do, and they do sit around quite a lot. I don’t like the way they don’t change their gloves between doing things” another told us, “This is my major issue. They do not wash their hands before putting gloves on, and they use one pair of gloves. They empty my commode, they do not change their gloves, then they give me a wash, I don’t want them doing that with the same gloves on” another person told us, “They don’t know how to do things, last week one of the carers washed up my cereal bowl with kitchen floor cleaner, and they didn’t change their gloves between helping me on the toilet and washing up”.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning. We found that the provider did not carry out any audits on medicines within the service except for medicines stock audits. This is contrary to best practice guidance set out by the National Institute for Clinical Excellence (NICE) NG67.

The services training that covered medicines awareness/administration was a mix of E-learning and face to face training; all staff had completed ‘Medication Awareness’ training which was held face to face this training was held for 30 minutes. E-learning for ‘Medication Advanced Administration’ had been completed by 10 staff out of the 42 employed by the service at the time of the inspection.

We looked at a person’s medicines and noted that they had been administered high risk medicines that were not in line with prescribing guidelines resulting in overdoses, we also found medicines patches being applied without body maps, this increases the risk of medicines patches being reapplied to the same area, reducing efficacy and potentially causing skin break down. We found widespread incidences of Medication Administration Records (MAR) not being accurately filled out or completed; this increases the risk medicines not being administered accurately putting people at risk of missed doses or overdose.

We found that As Required Medicines (PRN) protocols were not accurately completed, some were missing vital information such as circumstances for administration of medicines, how the person would request medicine, maximum dose per period and minimum interval information.