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• 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 from avoidable risk or harm.

The service was in breach of legal regulation in relation to safe care and treatment and staffing.

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 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 told us that there had only been 1 safety incident since the service was registered. This incident had occurred the day before our inspection and was currently being investigated. However, there was no evidence of any formal process in place to show how lessons are learned when accidents, incidents or near misses take place. A lack of auditing and quality assurance processes meant the service was ineffective in driving improvement and reducing risks to people. Furthermore, the absence of any documented team meetings meant it was not possible to see how safety information was discussed with the wider staff team, to promote a learning culture.

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

Whilst people and relatives told us that they had been involved in a face-to-face discussion before care was provided, there was no formal documented process to assess people prior to them receiving a service. Care plans lacked detail and did not provide staff with clear guidance on how to appropriately provide personalised care. One staff member told us that they had not seen care plans. Another staff member told us, “When paramedics arrive, they often ask for care plans, but we can’t provide them”. This meant there was a risk that people would not have a smooth transition to other services, should this be required.

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.

Systems in place where not effective in ensuring people were protected from abuse or neglect. The provider had not identified when people were at risk of neglect, and they failed to demonstrate a strong understanding of safeguarding. Whilst staff were able to describe what safeguarding was, not all were aware of how they would raise a safeguarding concern.

The service had a safeguarding policy in place, and the registered manger told us that staff were provided with a copy when they started their employment. However, some staff were unsure if they had seen it. Two staff we spoke with also told us that they had not undertaken safeguarding training in their current role.

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.

Risks associated with people’s care had not always been assessed, identified or managed to ensure people received safe care. The provider failed to ensure robust assessments and guidance were in place to mitigate risks relating to people’s health needs. For example, one person was prescribed a thickening agent. Their care plan contained no guidance or risk assessment regarding the appropriate thickness of fluid, for staff to safely support people in line with IDDSI (International Dysphagia Diet Standardisation Initiative) guidelines. Furthermore, another person with a diagnosis of diabetes although under the care of health professionals for this care need, there was no guidance in place for staff to follow so they were aware of signs of deterioration to be aware of, and escalation required to ensure the person received appropriate and timely care.

While care plans outlined people’s medical conditions, the provider had not implemented robust guidance for staff to support people with their health conditions on a day-to-day basis or in an emergency situation. For instance, risk assessments and guidance relating to skin integrity, nutrition, choking, mobility, diabetes, falls and refusal of care. Some staff told us they had not seen a risk assessment.

The provider did not always detect and control potential risks in the care environment.

The provider had completed environmental risk assessments, and some potential risks had been identified and documented. However, some staff told us they had not seen a risk assessment, and we could not be assured that everyone was aware of potential risks.

The service supported a person who required the assistance of 2 staff for all transfers. Support was provided by staff for 12 hours a day. When we sort assurances about fire safety the provider told us that Fire Officers had previously visited this person’s property and deemed that measures in place for evacuation were safe. However, this information had not been documented.

Lifting Operations and Lifting Equipment Regulations (LOLER) standards and checks had been competed on specific items of equipment such as hoists.

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 always make sure that staff received effective training, support, supervision and development. The provider did not maintain up to date records in relation to staff. Recruitment checks were not carried out safely. For example, 3 staff told us they had not undergone Disclosure and Barring Service (DBS) checks before commencing employment. This contradicted documentation completed by the provider indicating that they had. Furthermore, there was no evidence that staff had completed application forms which meant it was not possible to verify education, qualifications or any gaps in employment. When asked about this, the registered manager told us, “Some staff come through ‘indeed’ with a C.V and some are employed by word of mouth.” The registered manager confirmed that interviews took place but there was a lack of recorded evidence to show this.

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.

The majority of people we spoke with were satisfied staff used protective equipment correctly and provided safe, hygienic support. They told us staff consistently wore gloves and aprons during visits and disposed of them properly after use. Staff we spoke to were able to describe how they ensured good IPC practices.Information provided by the registered manager indicated that infection prevention and control training was provided to staff, however some staff we spoke with could not remember if they had undertaken this training in their current role. Furthermore, there was no documented evidence that spot checks were carried out to ensure staff competence in this area.

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

Medicine administration records were paper-based and kept in people’s homes. The provider did not have robust systems and processes to routinely audit these records to check people were receiving their medicines safely and as prescribed. Whilst periodic staff competency checks were carried out by the provider, not all staff were able to confidently describe what they would do, or what they would record, if someone refused to take their medication. Not all staff were knowledgeable about medicines prescribed for use ‘as and when required’, and protocols were not in place to support staff in knowing when these medicines were required.

We also identified that application of topical creams were not appropriately recorded.