Everkind Healthcare 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 newly registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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 always demonstrate a proactive culture of safety and learning. Although systems were in place to record and report accidents and incidents, the provider could not always demonstrate that safety events were fully investigated, staff practice was reviewed, or learning was recorded, shared and embedded.

The provider had systems to record and report accidents and incidents. However, following a person’s fall from bed, a staff member contacted the office before contacting emergency services, which was not in line with the provider’s procedure. There was no information to demonstrate there had been a significant delay in contacting the emergency services or that the sequence of calls had affected the person’s assessment or treatment. However, the available records did not demonstrate that the staff member’s response had been reviewed or that any learning from this had been identified and shared.

The incident record did not document lessons learned or the outcome of the provider’s review. The provider said the incident had been discussed with staff, but the relevant meeting record was no longer available. This meant the provider could not demonstrate what learning had been identified, who it had been shared with or whether staff practice had changed as a result.

Despite this, staff understood their responsibility to report incidents and concerns. One staff member told us, “We don’t cover it, we address it to prevent further mistakes.”

The provider worked with people and healthcare partners to establish and maintain safe, coordinated systems of care. These arrangements supported continuity, including when people moved between services or their care needs changed.

Care coordinators reviewed referral information before meeting with people to discuss their needs and preferences. This helped ensure that existing information informed the assessment process and was reflected in people’s care plans.

Pre-assessment processes considered potential risks, including lone working and behaviours that could place the person or staff at risk. Staff had access to up-to-date information through electronic care plans and said they were expected to review these before supporting someone new, so they understood the person’s needs, risks, preferences and the support expected of them.

Agency workers described receiving a handover from other staff when they arrived at a person’s home. This supported the sharing of relevant information between workers and helped maintain continuity of care.

The provider worked with people and relevant partners to understand what safety meant to them and shared concerns appropriately. However, staff did not consistently demonstrate a strong understanding of safeguarding.

Staff had completed training in safeguarding, mental capacity and equality. However, one staff member could not explain when confidentiality should be overridden to protect a person, while another gave limited information about how they would recognise signs of abuse or neglect. This created a risk that staff might not recognise a safeguarding concern, take immediate protective action or escalate relevant information promptly. There was no evidence that these gaps in knowledge had resulted in a safeguarding concern being missed. Following the assessment, leaders held a staff meeting to reinforce safeguarding responsibilities.

Despite these concerns, the provider had responded appropriately when known safeguarding concerns were raised. Records showed referrals had been made to the relevant safeguarding authority, CQC had been notified where required, and staffing arrangements had been changed to protect people. One person confirmed that management acted promptly after they raised a concern.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the capacity. Staff demonstrated an understanding of the MCA and their responsibilities to support people to make decisions wherever possible. Systems were in place to protect people’s rights under the Deprivation of Liberty Safeguards (DoLS). At the time of assessment, no one was deprived of their liberty or had restrictions placed on them.

The provider worked with people to understand and manage risks using a holistic and person-centred approach. Staff provided care that supported people’s safety while enabling them to make choices and continue doing the things that mattered to them.

Care plans contained person-centred risk assessments that reflected people’s health conditions, individual circumstances and choices. These considered risks including falls, self-harm, alcohol use, changes in mental health and hazards within the home. Staff were given guidance about how to recognise changes in people’s needs and the action they should take when concerns arose.

Staff understood how to reduce risks without unnecessarily restricting people’s independence.

The provider had effective systems to identify and manage environmental risks within people’s homes. Assessments considered fire safety, equipment, access arrangements and household hazards, while care plans provided staff with emergency information, including utility locations and evacuation considerations. Staff demonstrated an understanding of how to reduce environmental risks, such as removing trip hazards, and had completed training in health and safety, moving and handling, and fire safety. One staff member described the practical steps taken in people’s homes, saying, “We move items to prevent accidents. When the floor is wet, we clean it to prevent accidents. We make sure the lights are on so [person] can see and prevent falls.” This demonstrated that staff took proportionate action to protect people while enabling them to remain safe within their own homes.

The provider had sufficient suitably qualified, skilled and experienced staff who received support, supervision and development to help them provide safe care that met people’s individual needs.

The provider operated safe recruitment procedures and completed pre-employment checks to assess staff suitability. Staff completed training relevant to their roles and the needs of people the service was registered to support. This included training to support people with a learning disability and autistic people. Leaders assessed staff competence in areas including medicines administration and moving and handling. Staff received ongoing support through supervision, team meetings and regular communication with leaders.

The service used agency workers when required. The provider completed inductions and assessed relevant competencies, including medicines administration, to help ensure agency workers had the skills and knowledge required for their roles.

The provider had systems to prevent and control infection. Staff received training and followed hygiene practices, including handwashing and the use of person protective equipment (PPE). Observations carried out by leaders confirmed staff adhered to infection control procedures when preparing meals and providing care. PPE was available and monitored through stock checks. One person told us, “The staff always use gloves, masks, aprons, they keep a stock here and I can even use it myself.”

The provider did not always ensure that medicines and treatments were administered and monitored safely.

For one person, records showed two occasions when a worker administered a pain-relief medicine without allowing the interval specified by the prescriber. The person therefore received the medicine outside the prescriber’s instructions, creating a potential risk of adverse effects and avoidable harm. The provider investigated the error on the same day, contacted the person’s GP and took appropriate action. No clinical harm was identified.

The person was also prescribed a laxative medicine to be administered when required. Their care plan identified constipation as a known risk and required staff to monitor bowel movements and contact the GP if they had not opened their bowels for 3 days. Medicines records showed the laxative had been administered on specific dates. However, daily records did not consistently document bowel movements, or the reason medicine had been administered. This meant staff could not demonstrate that the medicine was given in response to an identified need or that its effectiveness had been monitored.

Topical creams were prescribed, but body maps within the person’s care records were blank and did not clearly identify where each cream should be applied. Staff understood how the creams should be used, and no incorrect application or associated harm was identified. However, the incomplete written guidance increased the risk that creams could be omitted, applied inconsistently or applied to the wrong area, particularly when care was provided by temporary staff who may not know the person.

The provider acknowledged the concerns and took action to strengthen medicines monitoring. This included introducing a bowel-monitoring task within the electronic daily care records and adding visual body maps to provide staff with clear instructions about where prescribed topical creams should be applied.