Archived: Social Care Solutions Limited (Northampton)

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 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 dignity and respect, safe care and treatment, good governance, staffing, and fit and proper persons in this key question. Risks to people were not being effectively assessed and accidents, incidents and safeguarding practices were not managed effectively. Recruitment processes were not operating effectively, and we identified shortfalls in staff training. Medicines were not being managed safely, and infection control practices were poor. Audits completed were ineffective. Systems and processes in place were not implemented effectively to support learning and improve safety.
 

This service scored 25 (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 based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety.
Lessons were not learnt to continually identify and embed good practice.

Policies and procedure for recording and reporting incidents were not followed. We found there was no consistent management review process in place after an incident and there was often a delay in these being reviewed by a team leader or manager. Staff told us, “Incident forms are collected when [team leaders] visit” or “a photo of the incident form is sent from the service mobile.”

We found examples of a physical altercation, falls, unexplained bruising, and a medication error where there had either been a delay in reporting, or a failure to investigate the incident accurately or fully. Staff lacked understanding about what constituted an incident. There was no evidence of learning being shared with the team, or a review of care plans and risk assessments following an incident.

The provider had an electronic incident management system, however, this had not been implemented effectively in the service. There was no adequate analysis of incidents to consider triggers, themes, and trends across the service that was being used to learn from and improve people’s experience. The processes in place to identify, record and report incidents were not robust, and the provider failed to investigate and learn from them accurately or fully. This meant that people were being placed at risk of harm from repeated incidents.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The area manager told us there was no formal process in place to assess people’s needs when they returned from an admission to hospital. This meant that staff did not fully understand people’s needs or associated risks on discharge from hospital, and people were at risk of returning to the service without the required equipment or support to meet their needs.

People had a hospital passport; however, we found not all information was accurate and up to date. For example, the resuscitation status, a diagnosis of prader willi, and acquired brain injury had not been added to hospital passports.

The area manager told us they were making changes to the admissions process; however, these processes were not in place at the time of this assessment. We were not assured that people would experience a safe transition if they were admitted to or discharged from hospital. This meant that people were at risk of receiving poor continuity of care.
 

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider did not share concerns quickly and appropriately.

The provider had safeguarding policies and procedures in place. However, we found staff did not follow these and these were not effective as there was often a delay, or no external reporting of potential abuse to the local authority and CQC.

We found examples of a physical altercation, falls, unexplained bruising, and a medication error where there had either been a delay or no safeguarding alert raised with the local authority, and there was a failure to accurately or fully investigate the safeguarding concern.

There was no system in place to identify that team leaders and managers had consistently delayed or failed to raise safeguarding alerts. Where investigations had been carried out, these did not adequately identify failings, or learning to be sufficiently assured people were being protected from avoidable harm and neglect. The local authority told us they were not assured by a provider led investigation, and this had reverted to the safeguarding team for completion.

The provider’s systems to identify, report and investigate safeguarding concerns to the local authority, and CQC were ineffective. This meant that people were at risk of abuse being unreported and action not being taken to protect people from the risk of harm.
 

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.

Risk assessment, positive risk taking, and positive behaviour support (PBS) policies were in place, however, we found these were not effectively used in practice to enable people to live fulfilling lives.

Risk and needs assessments were in place, however, these failed to adequately assess and mitigate risks. We found risk management plans for specific medical conditions such as diabetes, prader willi and epilepsy were either not in place or ineffective, as staff did not have sufficient information to know how to mitigate known risks or meet people’s needs.

The provider had a PBS team responsible for completing functional behavioural assessments and creating PBS plans. However, we found there was a lack of PBS support for people who had been supported by the provider for a significant period. The area manager had developed ‘interim’ PBS plans for some people and made a referral to the internal team, however, we were not assured the ‘interim’ plan had been developed by a suitably qualified practitioner, as these interim PBS plans did not meet people’s needs.

We found that where behaviour plans had been developed by the local authority the provider had not sufficiently incorporated these into their practice or taken ownership for the on-going review of their effectiveness.

There was no evidence people were supported to understand and manage risks.
 

The provider did not always support people to detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care.

People were not always supported to keep their homes safe and well maintained. We found there was a lack of processes in place to support people to escalate concerns about the living environment to the landlord. A relative told us, “I don’t think the house is safe.”

We found that some people’s homes required redecoration and modernisation. For example, there were bedrooms that required redecoration and damage to communal kitchens. Some communal lounges required redecoration and personalisation. There were concerns about facilities and the safety of some external environments, for example, unlocked outbuildings in disrepair used for storage and uneven pathways. A relative told us one toilet “doesn’t have a sink” and “the garden has crazy paving, it’s not safe.” Some people were not able to fully access their garden.

The provider had failed to supply the appropriate training and equipment for staff to complete all health and safety checks. For example, the process and equipment being used to complete legionella checks did not support the delivery of safe care.

The provider’s systems to support people to maintain a safe environment were not always effective. This meant that people were not always being supported to live in an environment that was person centred, safe, and well maintained.
 

The provider did not make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not work together well to provide safe care that met people’s individual needs.

There was a recruitment policy in place, however, this was not effective, and the systems did not support safer recruitment practices. The managers had the responsibility of making informed decisions about staff recruitment from the information provided by the provider’s recruitment team, the managers did not have all the information they needed to make safe informed decisions. Neither we nor the managers were not able to easily evidence all pre-employment checks had been completed for some staff. For example, we found gaps in employment history, health screening, and right to work in the United Kingdom. The provider has since provided evidence the required checks had been carried out, but the information had not been made available.

The provider did not have adequate systems to identify where staff had not had their mandatory training, competency checks, or subsequent refresher training. For example, we found competencies for moving and handling and medicines administration had not all been completed or refreshed in line with the provider’s requirements.

The provider did not have a process to identify where staff required or had not received training to meet people’s specific needs. For example, not all staff had received training in the management of diabetes, epilepsy, and dysphagia, or interacting with people with a learning disability or autism to an adequate standard. We found not all staff had been assessed as competent to complete delegated healthcare tasks in line with best practice guidance. For example, the management of a percutaneous endoscopic gastrostomy (PEG) tube or non-invasive ventilation (NIV).

The provider did not have an effective process to monitor the delivery of people’s care hours commissioned by the local authority. Relatives raised concerns about staffing levels. One relative said, “There should be 2 staff permanently but often there is only 1 member of staff.” Another relative told us, “Quite often they are short staffed.”

The provider did not make sure they safely recruited enough suitably qualified, skilled, and experienced staff and leaders to support people and ensure oversight of the service was effective. This meant that people were at risk of receiving poor care and not having their needs met.
 

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People were not always supported to keep their homes clean. We observed most of the homes we visited were not clean, tidy, or well maintained. For example, we found dirty kitchens, cookers, some heavily worn leather furniture, and in one home a dirty toilet and build-up of rust on the surrounding toilet frame.

There was no effective infection, prevention and control systems or processes in place. For example, at one home a staff member told us they did not have access to appropriate laundry sacks and would substitute these with a biodegradable bin liner.

People were not supported to arrange for the appropriate disposal of clinical waste in line with best practice guidance, and we observed in several homes there were no facilities for people to dry their hands after handwashing, and in one home no access to soap to wash their hands.

At one home we observed best practice was not followed in relation to the storage, labelling and disposal of food. Staff had recorded they had undertaken regular cleaning; however, these records did not match the cleanliness of the homes.

The provider’s systems and processes failed to protect people from the risk associated with lack of cleanliness and safe infection control practices. This meant that people’s dignity was not upheld and placed them at risk of ill health from poor cleanliness standards.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

There was a medicines policy in place, however, we found staff competencies for medicine administration had not all been completed or refreshed in a timely way. This meant people were not being supported by staff who had received adequate medicines management training.

Medicines were not always stored safely. We were concerned people with complex needs had access to other people’s medicines. For example, we observed medicines had been left in the kitchen. In one home we found medicine stored in the communal fridge and observed on several occasions the medicines room unlocked.

People did not always have a protocol for their ‘when required’ (PRN) medicines, and some PRN protocols were ambiguous. This meant staff did not always have the appropriate guidance to know when PRN medicines should be administered. At one home we found a person’s PRN medicine for pain relief had expired; it was unclear if this medication had been administered since the expiration date, as their records were not readily available.

We noted gaps in the medicine administration records (MAR) for the application of creams in response to skin concerns, and not all topical medicine administration records (TMAR) had been transcribed by a second person.

A medicine related incident had not been adequately investigated. Where the provider had given CQC assurances that staff had been retrained we found this did not include observation of medicine administration practice. Medicine audits had not been adequately completed and had not identified the concerns we found during this assessment.

There was a lack of adequate oversight from leaders in relation to medicine optimisation. This meant people were being placed at risk of harm from poor medicines management.