Ur Care Solution Ltd

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 newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation 12 (safe care and treatment) in relation to the failure to fully assess and mitigate risks to people, including ensuring staff had the competence to care for people safely, the care environment was safe, care equipment was assessed and medicines were managed safely. The provider was also in breach of legal regulation 19 (fit and proper persons employed) in relation to the failure to ensure staff had the qualifications, skills and experience required in line with best practice guidance.

This service scored 28 (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 investigate or report safety events appropriately. Lessons were not learnt to continually identify and embed good practice.

The provider was unable to provide evidence of any lessons been learnt from events. The registered manager explained that these were discussed one-to-one with staff but was unable to provide any examples.

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 provider was unable to provide evidence to ensure people’s care was continuous when moving between care services. There were no documents in place such as hospital passports or emergency health care plans which support people when moving through the care system. Pre-admission assessments had been completed but these lacked detail, were not person-centred and were contradictory.
 

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 service had recorded no safeguarding incidents since it was registered. The registered manager was unable to explain the correct process to follow should a safeguarding incident occur. We were therefore not assured that safeguarding incidents would have been acted on or reported appropriately if they had occurred.

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 assessments were brief and contradictory. It was not clear whether people were at risk of some hazards and mitigation was not in place for most hazards identified. For example, a pressure sore assessment identified a person was high risk, however staff were not recording information in the daily logs. There were numerous other similar issues.

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

There were limited risk assessments in place to ensure staff remained safe when providing care.

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.

Staff were not recruited in line with requirements. There was missing information about staff member’s previous care experience, gaps in employment and missing references. The provider employed a number of staff on sponsorship licences, during the assessment the licence was revoked due to multiple failings by the provider to meet the sponsorship requirements.

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.

There was no information recorded about people’s risk to infection or how to manage the risk of infection to people. The provider had not carried out spot checks on staff to ensure they were wearing appropriate personal protective equipment (PPE). The provider had not conducted an infection control audit.

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.

Records were inconsistent and unclear as to whether people received support with medicines or not. The registered manager said the service did not support people with medicines currently as they did not require it. We were not assured that people’s medicines were managed safely, or would be managed safely if a new person joined the service who required support with medicines. We requested records from previous people using the service who did receive support with medicines but the service were unable to provide this documentation. This was not in line with the General Data Protection Regulation (GDPR) which usually requires health care records to be kept for 8 years.