DORZ Care Services Limited

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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 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 people’s safe care and treatment, administration of medicines and staffing.
 

This service scored 38 (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. Managers did not identify or manage known safety risks. Lessons were not always learnt to continually identify and embed good practice. The provider had recently commenced working with commissioners to improve the quality of the service and at the time of assessment had not prioritised or detailed action plans to implement or embed improvements. For example, the provider shared with CQC guidance they had received regarding expected standards for “as required medicines” (PRN) protocols. At the time of assessment this had not been implemented. CQC had identified a number of concerns with medicine practices including management of PRN’s. The provider informed CQC that staff prompted people with medicines and therefore had not prioritised this as an area of care support that was within their remit. There was a fundamental lack of understanding and learning of the registered provider's regulatory requirements as well as a failure to ensure risks were not ignored and dealt with appropriately to ensure staff had access to guidance to support people's safety. A staff member provided feedback regarding how they learnt from incidents, “After a recent medication error in the service. I received additional training on medication management.”

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. There was not a strong awareness of risks and safety across people’s care journey. Some people supported by the service were receiving short term care arrangements following transitions from hospital. Most people’s records confirmed they presented with health conditions, some complex, and whose support needs could change quickly. Although information about people’s health needs was provided by people and key stakeholders, this was not always incorporated into the providers risk assessment and care plans to ensure staff had accurate guidance available to ensure a joined-up approach to safety. This put people at potential risk of harm. Some relatives confirmed shortfalls with the quality of the service they initially received. For example one relative told us, “We had one carer that was not a good fit for [loved one] at the beginning.” Another relative said, “[We] couldn’t find a regular carer”. People and relatives told us this had now improved; however, it was indicative of shortfalls in the initial assessment processes and matching with appropriate staff.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff told us if they had any safeguarding concerns they would report to the manager and follow the DORZ safeguarding procedure. Upon review of the procedure, we noted it failed to include the local authority contact details. The provider did not always demonstrate a positive safeguarding approach to managing risks and concerns. We reviewed a safeguarding investigation completed by the provider and were not assured the provider had considered risks to the wider service. For example, the provider focused on staff practice and shared an example of a reflective supervision. This was mainly generated from online resources rather than evidencing a positive risk management approach. It did not identify the need to ensure people’s risk assessments included consideration of choices around positive risk taking. Whilst we have identified concerns with the quality of safeguarding processes in operation, people confirmed that they felt safe when carers were in their home. A relative told us, “[Person] does feel safe with the carers”.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. There was a failure to understand the regulatory responsibilities around risk management and ensure that all risks had been considered and assessed to ensure people were safe when they received care and support. Known risks relating to people’s health were not always assessed or documented accurately which posed a risk staff would not know what action to take in the event of an emergency. For example, we reviewed records relating to fluid intake for a person who had been assessed at high risk of dehydration. There was no detail to confirm the provider had assessed or recorded this person’s Recommended Daily Amount (RDA) and as a result could not be assured records staff were completing mitigating risks of potential harm. We fed back to the provider and the manager told us, “We are aware that accurate documentation of fluid intake is crucial particularly due to any potential dehydration risks. The RDA for fluid intake will now be clearly documented in their care plan, so all staff are aware of their specific needs and can ensure that fluid intake is carefully monitored and recorded.” We identified a number of areas of risk management were not as detailed as others. For example, risk assessments had not considered potential increased risks associated with falls for one person who was prescribed anticoagulant medicines. The provider acted on our feedback and reviewed the care plans and provided staff with further guidance during our assessment. People and relatives spoke positively about how staff supported them to manage risks.

The provider detected and controlled potential risks in the care environment. They made sure facilities and technology supported the delivery of safe care. The provider has not always fully assessed or documented guidance for staff regarding equipment used for a person to move and position in bed safely. For example, care records identified a person needing support from 2 staff for moving and handling however, care records lacked information about how staff supported the person or the equipment they needed to use. The provider spoke of the processes in operation which provided assurance they understood their responsibility with staff health and safety and the need to work with people and stakeholders to ensure equipment was safe and used appropriately. One relative shared an example of how the staff worked with equipment such as mobility aids, “They are proficient in using them all”. One staff member told us, “I make the house safe by following cleaning regimes and reporting maintenance issues promptly.”

The provider did not make sure there were qualified, skilled and experienced staff. Staff were not consistently recruited through an effective recruitment process that was in line with regulation or ensured they were safe to work with people. Recruitment checks had not always included checking reasons for gaps in a staff members employment history to provide assurance of their suitability for employment. For example, the provider had not documented they had considered an employment gap of over 2 years for one staff member. We fed back to the provider and the manager told us, “We ensure that a Curriculum Vitae (CV) is submitted as part of the hiring process, which includes all relevant details of their past employment history and non – employment periods.” The CV they provided did not provide assurance non- employment periods had been considered.The provider had not always made sure staff received effective training and development in line with regulation. For example, “All health and social care providers registered with CQC must ensure that their staff receive training in how to interact appropriately with people who have a learning disability and autistic people, at a level appropriate to their role.” (Health and Social care act 2022). The provider had not identified this requirement which potentially increased the risk of staff not possessing appropriate skills and knowledge to carry out their role effectively. Following this being fed back during our assessment the provider took action to review their employment processes and ensure all staff completed required training.

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. People told us staff supported them to keep their homes clean. Staff received infection prevention and control training and had access to personal protective equipment (PPE). People and relatives told us staff practiced good hygiene, one person told us, “I am fussy and they do more than is needed including wearing foot covers.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The providers medicines processes had not fully assessed the level of support people required or ensured staff supported or administered medicines in line with their assessed need. For one person assessed as requiring time specific support with medicines to mitigate the potential impact of a significant health condition, staff had completed records evidencing their noncompliance with this instruction. The provider’s monitoring processes had failed to identify concerns or provide staff with detailed guidance to support this person safely. The provider acknowledged this person required time specific medicines. It was evident medicines processes were inconsistent as a result managers and staff lacked clarity as to what level of support this person required and this increased potential risk of harm. Some people were prescribed PRN (as required) medicines. A relative told us staff supported their loved one with medicines, “They do all of that, none of them grumble, they do the PRNs when needed.” However, there were no PRN protocols in place to provide guidance for staff about when these medicines should be given, whether people were able to request the medicine themselves, or what signs and symptoms staff should look for before offering the medicine. This meant people prescribed PRN medicines were at risk of not receiving this medicine safely or as prescribed. We were assured the provider was working with commissioners to address a number of identified shortfalls in medicine practices. Only staff who were trained and had been assessed as competent were able to administer medicines to people.