Archived: Achievers Care Solutions Limited

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 was the provider’s first inspection at their new location. At our last inspection we rated this key question inadequate. At this assessment, the rating remained inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service continued to be in breach of legal regulations in relation to people’s safe care and treatment, people being protected from the risk of abuse and neglect, staff training, supervisions and deployment, and recruitment processes.

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 service did not demonstrate a positive learning culture regarding risk assessments, incident reporting and care planning. Risk assessments were not consistently developed or updated to reflect people’s current needs, for example one person’s risk assessment did not accurately describe their needs around eating and incorrectly stated that they were at risk of choking. Incidents were not reported or recorded accurately, limiting opportunities for reflection and improvement.

The lack of robust systems for learning from incidents and updating key documents indicated a poor culture of continuous improvement and risk management.

This was a continued breach of Regulation 12 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014.

The provider did not have a clear system for assessing new care packages. There were no pre-assessment documents to evidence how people’s needs had been assessed prior to starting care. This posed a risk of the service taking on care packages without fully understanding the level of support people required.

They did not consistently manage or monitor the safety of individuals. They did not always ensure continuity of care, especially when people transitioned between different services. Additionally, people's care records lacked sufficient information for staff to provide safe and consistent care.

We did see some evidence of collaboration with other professionals, including social workers, Positive Behavioural Support (PBS) teams and communication with the local authority. This indicated some effort to work with external agencies, however the lack of formal recorded assessments limited the effectiveness of these interactions.

Relatives told us they felt their loved ones were safe. One relative said, “He is safe with [care workers].” Another relative told us, “He is very safe.”

Although we received positive feedback from relatives, we found this positive feedback did not reflect what we found. The provider did not have robust processes and systems to protect people from the risk of abuse and neglect. The provider failed to ensure people were protected from the risk of harm.The registered manager failed to appropriately address incidents, as these were not always identified, responded to or shared in a timely and suitable manner. For example, one person was placed at risk while in the community. Although we saw that the registered manager had informed a social worker at the Local Authority about the incident, a formal safeguarding alert was not raised and we saw no clear evidence of how learning had been applied to mitigate the risk of reoccurrence.

Staff were not adequately prepared to protect individuals from harm and abuse. Additionally, we were not assured all staff had a clear understanding of safeguarding or knew how to escalate concerns appropriately. For example, a member of staff we spoke with was not able to identify the different types of abuse or what to do if they needed to report safeguarding concerns externally.

The risks associated with people’s care were not managed in a safe way placing people at risk of harm. Processes for developing and reviewing risk assessments and care plans were not effective. There was a lack of structured oversight to ensure risks were regularly assessed, monitored and updated in response to changes in people’s needs.

Risk assessments were not robust and contained incorrect information about risks. For example, one person’s risk assessment recorded that they were at risk of choking, however this information was incorrect. In addition, information about what to do in an emergency was not clear. There were two references to calling "911" which is incorrect information and could delay staff in getting help in an emergency for people, placing them at risk of harm. This meant staff did not have accurate guidance to support people safely.

Although the registered manager advised that incorrect information had been removed from people’s risk assessments, the multiple errors and inaccuracies found in care records during our inspection meant risk assessments did not reflect people’s needs, placing them at risk of harm.

This was a continued breach of Regulation 12 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014.

People received personal care and support in their own homes and relatives of people who used the service told us they were happy with the carers and that their relatives were safe.

People using the service did not require any equipment to meet their needs and lived with their families. We saw reference to environmental risks in people’s care plans, for example to give the person space and to ensure the environment is free from hazards, but this was not elaborated on and lacked detail in order for care workers to know what these hazards were. There was no staff guidance on what action they needed to take to mitigate those environmental risks while keeping people safe.

People’s relatives were happy with the care workers looking after their relatives and this was expressed during the inspection. One relative told us, “[Relative] gets along with the carers and they are all very supportive of me.” Another relative told us, “I have nothing but good comments.”

The registered manager was unable to demonstrate that they had effective support in their role and failed to evidence whether staff received appropriate support, training, supervision or appraisal. Evidence that every member of staff completed an induction was not provided which meant staff were at risk of making errors due to lack of essential knowledge, placing people at risk of harm. Management failed to consistently carry out spot checks for all staff, neglected to assess staff competencies, and failed to identify potential risks that could arise from poor staff skills and performance issues to ensure people received safe and good quality care. This meant that staff may not understand the needs of people they were caring for and therefore safe care may not be provided. This was exacerbated with the lack of oversight from management by failing to carry out regular supervision or competency assessments.

During our inspection we looked at five staff recruitment files. We saw one staff member’s file that had a Disclosure and Barring Service (DBS) document but this was completed by their previous employer and was not transferable. There were no DBS checks records available for four staff members. The registered manager shared they had computer system access issues, therefore the DBS checks for all staff could not be found. In addition, references could not be located for four staff, with one staff member having references on file that had not been verified. This meant we cannot be assured that staff working with people were suitable or competent to support people safely, increasing the likelihood of harm.

People’s relatives told us they had no concerns around infection control practices when care was being carried out. Records showed that not all staff had completed Infection Prevention and Control (IPC) training and although in some staff supervision records we saw personal hygiene mentioned, IPC was not a regular theme. This meant there was a risk staff would not be following safe practices and national guidance to manage and reduce the risk of infection.

The service did not support any of the people using the service with their medication.