Light Care Services Limited Hampshire

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.

We reviewed 7 quality statements for this key question. We found the provider did not have processes in place to ensure people received safe care. People’s care and support needs were not always managed safely, and detailed care plans and risk assessments had not been developed. Systems did not ensure medicines were administered safely.

There was a mixed response from people and their relatives about whether they felt safe, however we could not be assured leaders protected people from abuse and neglect. There were no systems in place to demonstrate staffing levels were sufficient to meet the needs of the people and staff had not received training to equip them in their role and to ensure they could provide safe care to people. Recruitment processes were unsafe.

We identified 4 breaches of the legal regulations related to; safe care and treatment, including the management of risks and the way people’s medicines were managed, safe and effective staffing, safeguarding and ensuring fit and proper persons were employed.

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.

We could not be assured the provider had a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Records of complaints demonstrated complaints about care were not robustly reviewed, investigated or actions taken where required. We found when concerns were raised by people using the service or their relatives, records did not consistently show that these were investigated thoroughly. For example, we saw records where a relative of one person had raised concerns, and the outcome of this was logged as, “Information given by son was not accurate.” There was nothing documented to explain how this decision had been reached or how feedback had been provided.

The leadership team told us where issues had occurred these were shared with staff during staff meetings; however, the manager was unable to provide us of any evidence that these types of discussions had occurred. Additionally, where incidents, accidents and concerns had arisen this information had not been reflected upon in people’s care plans and no guidance for staff had been provided to staff on how to mitigate future occurrences. This meant we could not be assured people would receive ongoing safe care in line with their needs.

A staff member told us that if a member of staff wanted to raise concerns following an incident, the electronic record keeping system in place had a feature called “Raise a concern” which staff could use to log concerns. However, the service was unable to provide us with any evidence of these completed forms.

They told us that if concerns were raised, a referral would be made to the relevant organisation, such as the GP or community nurse team. We saw some evidence that concerns were raised sometimes with GP’s and community nurses however this was not consistent.

There was a lack of effective systems and processes in place to demonstrate incidents, accidents and near misses were appropriately investigated and the provider did not robustly monitor all aspects of the service frequently including, complaints, accidents, incidents and near misses.

We found although incidents had been recorded, these records had not been signed to indicate they had been reviewed by a manager and there was no evidence provided which demonstrated these were acted upon, investigated and analysed. Additionally, there was no evidence provided to indicate that learning from incidents were shared with staff. For example, care plans had not been reviewed or updated to include details about incidents. Therefore, staff were not provided with information to inform them how to reduce the risk of incidents recurring. This placed people at risk of continued harm and demonstrated lessons were not learnt to continually identify and embed good practice.

People and their relatives had no comments to make in respect of continuity between services.

The provider did not always work effectively 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.

Partners told us information from the service was not always forthcoming, with important safeguarding information not always being reported.

We found limited systems in place to monitor people’s safety, and those which were in place were not always used effectively. For example, it was not always evident that the service was following policies in relation to all aspects of care and the overall management of the service.

We could not be assured the provider worked effectively 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.

We could not be assured leaders protected people from the risk of abuse and neglect. There was a mixed response from people and their relatives about whether they felt safe.A relative said, “The carers are lovely, and my husband feels safe with them as he has regular carers” and a person told us, “I do feel safe.” However, one relative told us about a safety incident that had occurred due to poor care from untrained staff. They told us, “I reported the incident to the company management who said, 'oh dear’, no details taken down about the events that led to this health and safety issue and no investigation was completed. There has been no written communication from the company regarding this incident.” Another relative told us about how their relative received unsafe care from staff who did not understand the person’s needs.

Although the leadership team told us they were confident people were protected from harm and abuse, they were unable to provide us with evidence this was the case.

During our inspection we found no evidence which demonstrated consideration had been given to promoting people’s safety, improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

As part of the inspection, we requested information and records of incidents and accidents both verbally and via email on the 12, 18, 21 and 26 June 2024. We emailed the provider and advised, ”Any records not submitted by the 2 July 2024 at 12:00, will be considered to not be in place at the time of inspection.” This information was not received.

We were shown a safeguarding log on site; however, this had no logged safeguarding incidents for 2024. We requested additional records of safeguarding incidents be provided through the secure file transfer system; none were provided. We saw no evidence that safeguarding events were recognised, managed or investigated effectively.

We found an incident record while onsite which showed staff had been assaulted by people, but care records did not contain any information regarding this and no guidance for staff on what to do should this occur. This placed people and staff at continued risk.

People’s care and support needs were not always managed safely, and detailed care plans and risk assessments had not been developed. This included but was not limited to care plans and risk assessments in relation to diabetes, episodes of anxiety and distress for a person which sometimes led to verbal and physical abuse of staff, catheter management, pressure area care and the management of epilepsy.

For example, on review of care records for people living with diabetes, we found there was limited or no person-centred information or guidance for staff in relation to people’s blood sugars and what results were normal for people. This meant should people’s blood sugar levels be outside their normal range this may not be recognised and escalated appropriately.

Additionally, we identified some people had urinary catheters in situ; however, there were no catheter care plans in place. There was no guidance for staff on how to monitor for signs of a urine infection or how to maintain the patency of the catheter or how to clean it. In one person’s daily records staff had documented, “We emptied catheter bag of 100ml of thick yellow urine” and “Emptied catheter of 200ml concentrated urine.” Although staff had documented that they had encouraged the person to drink, there was nothing else recorded to indicate they had assessed the person for signs of a urine infection or requested health professional input.

Where people were at risk of skin breakdown, formal skin integrity risk assessments had not always been completed. This meant systems were not in place to mitigate and manage risks to people’s skin to allow issues and concerns to be identified in a timely way or acted upon effectively.

The example’s given demonstrates people were placed at risk of significant harm.

The leadership team indicated they knew how people's needs and risks should be met and managed but had failed to ensure this as risk assessments were not in place and records of care lacked important person-centred information.

During the assessment the service failed to provide evidence of how they safely managed risks.

People were at risk of harm because the risks to them were not monitored or reviewed. Risks to people's health and welfare were not always assessed and not correctly documented. Care plans lacked detail of people’s specific needs.

We did not receive feedback from people or their relatives in respect of environmental safety.

We did not receive feedback from staff or leaders in respect of environmental safety.

We could not be assured staff and leaders supported people to keep their homes safe, if required. Although there was a business continuity plan and a policy in place which referred to the safety of buildings and external environments we were not assured these were followed. For example, there was no evidence provided to us which demonstrated leaders had considered people's internal or external environments through the completion of risk assessments or audits to identify and support the mitigation of risks to ensure people and staff's ongoing safety.

We received mixed feedback from people and relatives about whether they were provided with care from skilled and experienced staff and the timing of care calls, with some significant concerns about staffing skill and training. Comments included, “The carers are normally on time, but don’t always let us know if they are running late” “The carers are lovely, and my husband feels safe with them as he has regular carers” and “They are on time and stay and do the jobs they need to.” However, other people and relatives told us, “I do feel rushed as they watch the time and go on the dot after they have completed their time, so sometimes there is no time to have a chat,” “The carer was late this morning by 45 minutes and they had no idea about [person’s] needs and did not know what to do” and “[Person] had 3 carers to begin with so we both got to know them, they were untrained but between us we managed to get them to know [person’s] routine and what they needed to do….but now they no longer call, and we have different staff that don’t know the job.”

Direct feedback from staff in relation to staffing levels and training was limited. However, we received concerns prior to and during our inspection from professionals, people who use the service and their relatives and whistleblowers that staff were expected to work excess hours without breaks, staff members were often tired, and staff received limited and poor levels of training.

We discussed staffing levels and staff employed with leaders and requested a staff list including sponsored and locally employed staff on more than 3 occasions. When this list was eventually provided, we found this was not detailed or clear as to the numbers of staff currently employed and which of these staff were employed though overseas sponsorship.

As part of this assessment, we also requested contact numbers of staff members from leaders (with staff consent for these to be shared) and we were provided with names and numbers for 7 staff members. Our attempts to contact these staff members were unsuccessful as there was either no answer or the number was not recognised. We requested an up-to-date list for contacts and received a list with no phone numbers on. The next submitted list had phone numbers on and on the 9 July 2024, we attempted contact with 7 staff members, unsuccessfully. One ‘staff member’ on the list did answer however, told us they did not work at Light Care. This shows a lack of oversight of staff employed.

Although policies and procedures were in place in relation to staffing and recruitment, we could not be assured these were being followed.

There were no systems in place to demonstrate staffing levels were sufficient to meet the needs of the people. The leadership team was unable to provide us with assurances people’s changing and increasing needs had been effectively assessed, reviewed or considered to help ensure staffing levels were sufficient.

The management team told us supervision was provided to staff 3 monthly but was unable to provide evidence these had occurred as described. Of the 7 files reviewed, only one file had reference to one supervision meeting. Therefore, we could not be assured staff were appropriately supported in their roles.

We could not be assured all staff had received training to equip them in their role and to ensure they could provide safe care to people. The management team told us, new staff received training before they started employment. The provider said, “We've got our mandatory training in place, including medication training. Training is done face to face and then we've got online training.” However, although we requested evidence of training multiple times, including a training matrix, training certificates, evidence of completed refresher training, details of training content and records showing competency assessments were performed appropriately, these were not provided. The only information provided was one staff member training certificate which contained multiple training subjects with no date each had been completed nor reference to the contents covered in the training session. This meant the management team were unable to demonstrate effective processes were in place to ensure staff had the skills, experience and training to provide safe, effective care to the people they supported.

The provider was unable to demonstrate systems were in place to ensure safe recruitment processes were being followed. We looked at 7 staff files and of those we found inconsistent evidence of conduct in previous roles being sought prior to employment. For example, there was no evidence this information had been sought or obtained for five out of the seven staff files reviewed, application forms were not always completed in full, and no records of interviews were kept. Furthermore, the provider was unable to demonstrate checks had been completed with the Disclosure and Barring Service (DBS) for all staff. These checks are required to help ensure staff employed do not have past convictions and conditional cautions and helps employers make safer recruitment decisions. This meant staff had been employed into the service without having all the required pre-employment checks in line with the statutory requirements and placed people at risk of received care from unsuitable staff.

Prior to our assessment we received concerns from people and relatives that staff did not always adhere to infection, prevention and control (IPC) processes. Feedback from people who use the service included unsafe disposal of personal protective equipment (PPE), lack of effective infection control systems in place and staff not always working within IPC policy.

During the assessment we received mixed views from people and relatives about the IPC management. People and relatives’ comments included, “The carers wear their masks, gloves and aprons”, “They [staff] dispose of soiled gloves and aprons in a bag and then dispose of them in the outside bin” and “I witnessed the carers not changing their gloves after they cleaned [person] when they had soiled, I asked them ‘why did you not change your gloves …they were dirty?’ and they told me they were short of gloves.”

The management team told us staff were provided with Personal Protective Equipment (PPE) as required. However, they were unable to provide us with evidence how they assured themselves this was worn, used and disposed of appropriately.

From discussions with the management team and the lack of information they provided in relation to staff training we could not be assured staff had received training in relation to infection, prevention and control or PPE.

Although we found there was an infection, prevention and control policy in place we identified this was not being followed. For example, this policy stated the service should have an ‘Infection Prevention Lead’ in place however the management team were unable to provide us with information as to who this lead was. Additionally, the IPC policy referred to an IPC audit, however, when this was requested, this audit could not be provided. This policy also highlighted ‘daily observation of infection control was to be completed by the provider or a designated other to demonstrate a responsive means of quality assurrance.’ There was no evidance made availible which showed this had been completed.

Therefore this demonstrates processes to ensure people were protected from infection, cross contamination and ill health were not in place or followed placing people at continued risk of harm.

Whilst most people were not supported by staff with their prescribed medicines, on review of medicine management records we found the management of medicines was not safe. This placed people at risk of harm.

Medicine management was discussed with the leadership team, and it was evident they lacked skills, knowledge, oversight and understanding of safe medicines management and specific medicine support needs of people using the service. For example, a member of the leadership team told us no one they supported were prescribed, ‘as required’ (PRN) medicine. However, on review of Medicine administration records (MAR) we identified this was incorrect. For example, one person’s MAR dated 1 June- 30 June 2024 stated they were prescribed, paracetamol, topical creams and medicine to relieve constipation to be taken when needed. These prescribed medicines did not have specific PRN protocols in place to provide staff with guidance of when, how and why this medicine should be administered, or when to escalate concerns. This placed people at risk of not receiving this medicine safely.

The service did not have safe systems for appropriate and safe management of medicines. Although there was a medication policy in place who could not be assured this was followed.

The leadership team was unable to demonstrate safe systems were in place to ensure people were supported to take their prescribed medicines as required. For example, one person was prescribed anti-seizure medicines, but MAR charts had not been completed from 26 August 2023 to 28 September 2023. Additionally, gaps were found in the MARs during October 2023, November 2023 and December 2023 which demonstrated this medicine had not been administered as prescribed. We found this medicine had been changed on 19 January 2024, but the MAR had not been completed since. These findings were discussed with the leadership team who told us daily records showed staff had administered the medicine and recorded this in a narrative text, but the administration had not been set up on the electronic system to ensure the medicine was given as prescribed. This had not been identified by internal systems and processes for nearly 6 months and placed this service user at risk of not receiving this vital medicine, increasing risks of seizures and avoidable harm.

We requested copies of medicines audits multiple times from the leadership team, both verbally and via email, however no evidence of consistent effective audits was provided. It was unclear how the leadership team could assure themselves that medicines had been administered safely.

Medication support plans did not detail how staff could support people with taking their medicines and we could not be assured staff had received effective medicine training or if robust competency checks had been completed.