Karrthikeya Health Care 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 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 regulations in relation to people’s safe care and treatment, safeguarding, and fit and proper person employed.

This service scored 31 (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 events. Lessons were not learnt to continually identify and embed good practice.

The provider did not have systems and processes in place to collect, review and use information to support learning or drive improvement. The registered manager confirmed there were no arrangements in place to review incidents, complaints or other available information to identify themes or inform service development.

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 service did not engage with healthcare professionals involved with people’s care and support. This meant information about people’s health conditions were not accurate and up to date. Following our request for an action plan the registered manager sought guidance from a GP to clarify a person’s support needs during mealtimes.

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.

People were not protected from the risk of harm and abuse. Staff failed to recognise an act of abuse against a person and neglected to raise a safeguarding alert with the registered manager or with the Local Authority. The service failed to have effective systems and processes in place to investigate, immediately upon becoming aware of, any allegation or evidence of such abuse.

During the inspection, we raised 2 safeguarding alerts to the appropriate authorities regarding unsafe practises that placed people at 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.

The service failed to identify risks associated with people’s conditions. Care plans had no information to support staff to help people to remain safe. Guidance from healthcare professionals was not adopted into care plans and risk assessments were not in place. Daily notes highlighted that one person was supported to eat in an unsafe manner and against the advice given by a healthcare professional.

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.

The provider did not have effective systems in place to manage the impact of extreme weather conditions, such as snowstorms. Care staff did not have access to appropriate guidance and contingency plans, to maintain safe and consistent service delivery during adverse weather.

The service used digital care-recording technology, the registered manager was unable to access the system, and there was no continuity plan to ensure care records could still be retrieved when needed.

Environmental risk assessments were available to support staff working in people’s homes; these assessments contained basic information.

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.

The provider did not have a safe recruitment process in place. The service did not always ensure the appropriate Disclosure and Barring Service (DBS) checks had been conducted.

There was no documented evidence that the provider had assessed whether staff had the necessary qualifications, skills, and experience required for their roles

No supervisions and appraisals had been completed. Staff supervisions were provided following our request for an action plan. We noted all the supervisions contained the same text, and verbal responses recorded were word for word the same from each staff member, we questioned the authenticity of the documents with the registered manager. They advised they would make improvements.

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

Staff told us they had access to PPE. The service’s Infection Prevention and Control (IPC) Policy and Procedure belonged to another provider. This meant it wasn’t fit for purpose as it contained information relating to different roles and local authorities. Following our request for an action plan to be completed the provider purchased a new IPC policy. The IPC policy had not been completed and important information such as the IPC lead and local health protection teams were missing.

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.

The provider did not have the necessary systems, processes, or oversight required to ensure safe and compliant medicines administration. The service did not follow appropriate legal and medicine management guidance for the administration of covert medicine. Care plans contained inaccurate information and did not outline how people wished to be supported with their medication.

A complete and accurate Medicines Administration Records (MAR) was not maintained for every medicine prescribed. Photographs and allergy information were not consistently recorded. Handwritten MARs were used without meeting required safeguards, including double‑checking by a second competent staff member.