Care In Our Hands 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.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

The provider did not always learn from incidents and accidents. The provider had 2 instances of a minor injury to staff cause by needles Staff were given accurate information and advice following this incident; however, the provider had not implemented this advice into policy to reduce the risk of it occurring again. Therefore, lessons were not learnt and appropriate responses implemented 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 make sure there was continuity of care, including when people moved between different services. The provider did not have hospital passports in place to support people’s wellbeing and ensure essential information was available should they require admission to hospital.

The provider did advise that they did complete an initial needs assessment before people started using the service, however this was not always clearly documented and there was no clear evidence that initial assessments were completed. The provider was taking action to improve on these areas.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

Staff had the skills and knowledge to identify and report safeguarding concerns and where confident appropriate action would be taken by the management team. Safeguarding concerns had been suitably reported to relevant professionals, and action taken to safeguard people. People’s relatives were reassured by support provided and all the relatives we spoke to felt the service was safe.

The provider did not always work well with people to understand and manage risks. During the assessment, we found evidence that risk assessments did not always reflect people’s needs. For example, people did not have clear guidance for how to support people to mobilise safely when using moving and handling equipment. There was also a lack of guidance regarding specific health conditions such as diabetes or epilepsy and the associated risks. During our assessment, the provider told us they were in the process of reviewing all care plans and risk assessments and would ensure this information was captured.

The provider detected and controlled potential risks in the care environment. Staff monitored people’s homes for potential risks to their safety, and the provider ensured risk assessments were in place. Where concerns were identified, the provider took immediate action to maintain people’s safety, resolving concerns where possible and reporting them to people’s relatives or professionals where needed.

The provider did not always make sure there were enough qualified, skilled, and experienced staff.

Staff were not always recruited in line with safe recruitment practices. Staff files we reviewed did not have all pre-employment checks completed or documented before commencing their roles such as references. Furthermore, staff had not always completed all training relevant to their role. This contradicts both the providers policy for safer recruitment and training. The provider had a new induction process which provided a consistent learning process for new starters. The provider explained the new induction process was implemented to increase retention, alongside an action plan to improve their training processes.

The provider assessed and managed the risk of infection. The provider ensured staff were trained in infection prevention and control (IPC) and had access to PPE which was used appropriately by staff. An appropriate IPC policy was in place. Staff said, “We have enough PPE and we can always get more and know when to use it, I have completed my infection control training.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. The provider did not always ensure that medication was administered as the prescription instructed. For example, some medication was required to be administered with food, however daily records identified there was no food consumed at the time this medication was administered. Furthermore, reasons why medication was refused was not clearly documented. We discussed this with the provider, who agreed to review their medication processes to improve this.