Fixby Healthcare Ltd

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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 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found systematic failings in the management of the service, which meant the provider did not facilitate an effective learning culture. For example, we found issues relating to risk assessments, mental capacity assessments, medication records and staff training which had not been identified by the provider.

Staff listened to concerns about safety and investigated and reported safety events. Following incident and accidents actions were taken. For example, the registered manager identified a medication error and carried out a supervision with the staff member and provided further medication training to prevent future incidents.

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 worked collaboratively with the local authorities to ensure people received a safe transition into the service.

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. Staff ensured people were free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff received safeguarding training and knew how to report concerns. One staff member said, “It’s to protect individuals and their human rights. We protect people from harm and neglect. It can help to prevent harmful incidents.” However, the provider did not have audits in place to show how the oversight of safeguarding incidents were managed.

The provider did not always have risk assessments in place to guide staff on how to manage risks. For example, 1 person had a chair lift and there was no risk assessment in place to inform staff of how this should be used safely. Fire risk assessments were not in place for people who were prescribed paraffin-based skin products. We found no evidence that anyone was harmed and the provider agreed to complete the risk assessments following our feedback.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. One staff member said, “I have one client who I make sure has everything is in place when I’m leaving. We leave them with a drink and water. We make sure [Name] has their commode. I make sure their surroundings are safe before I leave. We help them to shower, and we use the stair lift.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The registered manager said, “We do a visual check of risks within people’s homes. If the [person’s] home is not good, we will speak to the family.”

The provider made sure equipment, facilities and technology supported the delivery of safe care. The registered manager said, “We do the checks as we go. We check the equipment on each visit and check it’s in good working order and clean. We can ring services if something needs to be fixed, or we can speak to the family.”

The provider made sure there were enough staff. They worked together well to provide safe care that met people’s individual needs. We also saw evidence of spot checks being carried out to ensure staff were competent in their role. Staff told us they had enough time to carry out visits and spend time with people. The provider had a recruitment process in place which included; interviews, an induction and shadowing of more experienced staff. Staff received training however, we were not assured that all training had been completed at the start of people’s induction. For example, one staff member had not completed their medicines and moving and handling training before providing care.

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. One staff member said, “Every week [Name of registered manager] makes sure we get gloves, and we can stock some in people’s houses and in my car.” The registered manager said, “We wear personal protective equipment as soon as we enter someone’s house. I take a box with aprons and foot protectors for those people who have wet rooms. When we are done with them, we take it off and put it in the bin.”

People received their medicines as prescribed, however we were not assured that medicines management was robust. We found one person did not have a risk assessment in place for flammable ointments or a topical protocol provided for this medicine. One person was given a homely remedy by the service however, there was no record of how and when this was given.