Utopia Care Limited - Thurrock Branch

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 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.

The service was in breach of regulations in relation to fit and proper persons employed and safe care and treatment. The registered manager had not completed the appropriate checks to ensure that staff were recruited safely into the service. Staff did not always assess risks to people's health and safety or mitigate them where identified. Risk assessments were incomplete and did not include risks we identified during our assessment. People did not always have detailed, accurate and up to date care plans to guide safe practice.

However, there were enough staff to ensure people’s safety and meet their needs.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported incidents. The care manager identified lessons learnt following accidents, incidents and complaints however, care plans and risk assessments were not always updated accordingly to ensure staff had up to date guidance to prevent similar incidents from happening again.

Management shared learning with staff from incidents, accidents, complaints and safeguarding so that the service could continually improve and develop positive outcomes for people. Information was shared with staff through supervisions and meetings. A member of staff told us, “The manager keeps us up to date with any changes.”

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The registered manager told us, “A meeting takes place to carry out a full assessment before we commence a support package to determine if we are able to support the individual or not. We also look at what additional training our staff may need to ensure the person receives the best support.” Staff told us they read through the care plans to ensure they had all the information they needed to provide support safely. A relative told us, “We had a meeting with the manager before the package started, and they asked us all the necessary questions. They took their time to get to know [relative] and talked about how we would want things done.”

However, not everyone had a copy of their hospital referral kept within their electronic care plan. This meant we were not assured staff had the correct information to deliver support safely.

The service 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, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The registered manager had raised safeguarding concerns appropriately and had worked with the local authority to investigate these to ensure people were being safeguarded.  Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people including informing other agencies if they were concerned about action being taken. A staff member told us, “I would report to my manager, and I would escalate to Local authority if I needed to”.

Risks to people's safety and wellbeing were not fully assessed and recorded. Management plans did not provide enough detail as to how identified risks should be managed and mitigated. For example, there was no information available to guide staff on how to support a person with diabetes should their blood sugar not be within the normal range,. This meant that staff may not be able to respond appropriately to changes in the person’s medical condition potentially placing them at risk of harm.

People's care plans and risk assessments were not personalised, with the information staff needed to provide support safely. People who were epileptic did not have care plans or risk assessments in place. Risks associated with their epilepsy were not considered or documented. A person who was at high risk of developing a pressure sore did not have information in their care plan on the current status of their skin to enable staff to monitor and identify changes in skin integrity.

People received personal care and support in their own homes. People and relatives told us they had not seen a completed environmental risk assessment to provide staff with guidance on how to keep people safe and minimise risks in their own home environment.

The care manager told us, ''We involve families and health professionals when formulating and reviewing the care plans and work closely with them on a regular basis.'' However, we found risks to people's safety and wellbeing were not fully assessed, recorded, or provided enough detail as to how identified risks should be managed and mitigated.

The registered manager had not always ensured staff were safely recruited. We saw gaps in recruitment files, such as staff not having a completed application form containing a full employment history, incomplete documentation on staff files in relation to their interview and medical health declaration, and not all references received had been verified. There was no evidence the registered manager carried out a regular staff file audit. This meant the registered manager could not be assured that staff were suitably skilled, qualified and safely recruited to meet people’s needs.

Staff were subject to Disclosure and Barings checks (DBS) when they first applied to work at the service. These checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff told us they were supported with an induction and given the opportunity to shadow more experienced staff when they first started working. However, the induction on file comprised of 1 day, did not include shadowing shifts or completed training and did not demonstrate a robust induction had been completed to enable staff to carry out their role and responsibilities effectively.Following the inspection, the registered manager revised their induction template to include shadow shifts. There was enough staff available to provide safe and consistent care to people safely.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had undertaken infection prevention and control training and were provided with personal protective equipment (PPE) which could be collected from the office. A member of staff told us, “I wear PPE when required, such as gloves and aprons during personal care and masks if needed.” A person told us, “All staff wear PPE, and I feel very safe when they are here.”

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found protocols missing in some records for medicines prescribed as required (PRN). Protocols are important as they help staff understand when it is appropriate to offer PRN medicines. The care manager told us they will update medication records to include a PRN protocol. Following the inspection, the registered manager told us they have amended their electronic medication system to ensure staff were recording PRN medicines correctly.

However, staff had received training in managing medicines and had their competency checked. A member of staff told us, “I had my medicines training, and my manager carried out observations and checked my competency.” Staff we spoke to were knowledgeable about the people in the service and their medicines needs.