Platinum Care Services

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. At our last assessment we rated this key question Good. At this assessment the rating has changed to 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.

We found shortfalls in the management of risk, health and safety and infection control. The service was in breach of legal regulation in relation to people’s 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 had systems in place to facilitate learning, we found these were not always robust. The provider had identified areas for wider analysis.

The provider had systems in place designed to facilitate learning, but these were not always robust. These were being strengthened at the time of our inspection. This included demonstrating where learning from safeguarding and incidents had taken place to mitigate reoccurrence and to evidence where learning from these had been incorporated into day-to-day practice. Although analysis of incidents was taking place, this was not always detailed. The provider had identified this themselves and were in the process of ensuring a wider analysis took place.

We found significant failing around infection control and environmental risks. The provider responded promptly during the assessment. Whilst there was no evidence anyone had been harmed, these actions were reactive and showed that systems had not been effective in identifying and addressing risks and promoting a culture of safety.

The provider told us Governance meetings with senior managers were held regularly to discuss risks at the service. Staff spoken with understood their responsibility to raise concerns and report incidents and accidents.

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.

There were systems in place to ensure people’s needs were appropriately assessed before they started using the service. These included a combination of face‑to‑face assessments and reviews of relevant records to inform safe admissions.

People had hospital passports which included details about how best to communicate with the person, important contacts, medicines and their physical health and emotional wellbeing needs.

People who used the service had lived there for many years. The staff knew them well and understood their needs and wishes.

There were systems in place for reviewing people’s needs. The staff team had contact with professionals from outside of the home who supported people with their health, medical needs and behavioural support. This included consultants, GP’s and learning disability specialists.

A healthcare professional told us they had no concerns regarding people’s healthcare monitoring. They told us people are supported to attend regular health checks and are supported when needed with any follow up investigations.

The provider worked with people to understand what being safe meant to them and how to achieve that. However, improvements were required to strengthen safeguarding arrangements and how learning from safeguarding incidents was consistently shared and embedded in day-to day practice.

Shortly before our inspection we received some information of concern regarding poor care and concerns about hygiene standards. The concerns were shared with the local authority and were still under investigation. We also considered this information as part of our inspection and the concerns regarding poor hygiene standards were supported by our findings. Separately, we witnessed 2 incidents during our inspection. The provider took the appropriate action, and referrals were made to the local authority. They told us regarding the 1 incident that further staff training would be provided.

During the inspection the provider shared with us details of recent improvements made to strengthen safeguarding processes, including improving how they showed learning from safeguarding incidents was shared with staff and implemented into day-to-day practice.

Relatives told us they had no concerns about their family member’s care. A relative told us, “I have no concerns about the safety of [person’s name] and believe they are treated with dignity and respect, I feel they are safe and well cared for.” Another relative told us, “I feel they are safe, well cared for and looked after, [person’s name] seems to be happy and contented, and I feel the staff are well trained and competent in dealing with their needs and requirements.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS authorisations were in place.

The registered manager was aware of their responsibilities in ensuring people were protected from abuse. The provider had policies and procedures in place to guide staff on how to respond to any allegations of abuse. Records confirmed that staff had received safeguarding training, which supported their knowledge and understanding of how to keep people safe.

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 consistently safe and supportive.

We observed some mixed interactions between people and staff. Whilst some observations showed staff were kind and confident in their approach to people, we also saw, at times, a lack of interaction or poor interactions from staff. We observed an incident when a person became distressed and we were concerned about how this was dealt with by staff. The provider took immediate action and confirmed it was not an approved moving and handling or safety intervention. The person’s wellbeing was checked, and the appropriate referrals were made. The provider told us they also reviewed the person’s care plan and risk assessment, and refresher training was scheduled to take place with the staff team.

Some risks to people were managed by implementing restrictions in the environment. These restrictions, including keypads on bedroom doors, to prevent people going into other people’s bedroom, were documented within the provider’s Environmental Risk Assessment, which recorded the rationale for their use. The restrictions were also reflected in individual DoLS authorisations where appropriate. Improvements were required to strengthen the recording of whether the restrictions could be lessened.

Environmental risks were not always identified or addressed in a timely way. During the inspection we observed a number of concerns that indicated potential risks to people were not managed safely or proactively. This included the storage of COSHH items (Control of Substances Hazardous to Health) in an unlocked cupboard in the kitchen. When we asked staff about this practice and the potential risks to people, we received inconsistent responses, that did not reflect the provider’s policy on storing these items securely. In addition, we saw other potential risks in the environment that had not been managed promptly by staff to keep people safe.

People had care plans and risk assessments in place with guidance for staff on the techniques and strategies to use when responding to incidents. These were reviewed with the relevant people. This included Positive Behaviour Support (PBS) plans. These are plans that enhance people’s life while reducing the likelihood of distressed behaviour. Staff we spoke with were able to tell us how they supported people when they were distressed.

People’s relatives told us staff managed risks well to keep their loved ones safe. A relative told us, “I have no concerns, if there is a problem staff deal with everything, staff are very good at deescalating should a situation arise. I find all staff and management to be open and honest, and experienced to deal with [person’s name] needs and requirements.”

The provider did not always make sure that aspects of the premises and facilities supported the delivery of safe care.

People were at risk from environmental hazards which had the potential to cause harm to people. The home was not clean, tidy or well organised. We saw an unlocked electrical cupboard, damaged fire doors and bushes and nettles around the garden exits were overgrown and required cutting back.

We requested WMFS visited the service. The provider confirmed to us that fire-safety risks were being actively identified, prioritised and progressed and the fire authority were engaged in this process.

The provider did have some plans for on-going improvements to the home and this included work to some bathrooms and flooring replacement and they shared this information with us.The provider told us the risks in relation to the damaged flooring had been identified and specialist flooring was to be provided. They also told us about some difficulties they had experienced with the recent recruitment of a maintenance person. The provider took immediate action on a number of the issues raised and we saw significant improvements had been made to the home on day 2 and day 3 of our inspection.

There were enough qualified, skilled and experienced staff to meet people’s assessed needs. Improvements were required to strengthen the consistency of care practice, supervision and staff development.

Our observations found some staff were confident in their approach to people. However, we also saw at times limited or no interaction from staff. We found the issues relating to general health and safety and poor cleanliness indicated a lack of teamwork and staff accountability. The provider told us they had identified some care practice issues and were planning some ‘back to basics’ training for staff. The provider told us a staff appraisal system was in progress, and work had taken place to strengthen staff supervision and induction process. Staff had received training relevant to their role, and topics related to supporting people with learning disabilities and autistic people.

There was enough staff to meet people’s needs. Staffing was allocated based on people’s individual assessed needs and the registered manager had a system in place for matching staff to people. The registered manager worked alongside funding authorities to ensure people received the support they needed to meet their needs. The provider had carried out pre-employment checks to ensure staff were safely recruited.

The provider did not assess or manage the risk of infection effectively.

The home was not clean, tidy and well organised. Infection prevention and control practices were not consistently effective. Cleaning regimes and laundry practices did not ensure compliance with current legislation and best practice guidance. The laundry environment was observed to be cluttered and dirty. There was a damaged door, debris on the floor, no dirty to clean flow for clothes, no visible procedure for handling soiled linen, no immediate access to gloves, aprons and PPE and no access to paper towels for handwashing. There was no storage system for mop and buckets, these were seen to be piled in the corner of the laundry.

The kitchen was unclean; there was a build-up of debris in the fridge freezer seals. Cupboards for storing food items were dirty and some food items were not secured in packaging, which raised the risk of food contamination.There was a malodour in several parts of the home, including people’s bedrooms. The main toilet had a worn, dirty toilet brush, and there was no lid on the bin. There was stained and damaged paintwork throughout the home. The flooring was damaged in a number of places throughout the home and this presented as a hazard and made cleaning difficult.

Cleaning schedules and checks were in place; however, these had not been effective. The provider acted during the inspection to address all the concerns, including deep cleaning and changes to the environment. However, these actions were reactive and highlighted that systems were not consistently effective in maintaining infection control standards. Theprovider told us the flooring risks had been identified as part of the provider’s wider improvement plan.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as prescribed. Staff had received training in the management and administration of medicines, and systems used for the management of medicines were safe. The provider had recently strengthened their checks on assessing staff competency in administrating medicines.

Where people were prescribed ‘as required’ medicines to support them in times of distress, there was guidance in place to ensure these were administered consistently and only when required. People’s medicines were reviewed and the registered manager was aware of the national STOMP (Stopping over medication of people with a learning disability and autistic people) project.

Checks were carried out to ensure medicine stock levels were accurate and audits were also completed to provide oversight and identify any areas where improvements were needed.