Scodef Care

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 inspection for this service. This key question has been rated requires improvement.This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment potential risks posed to people had not always been assessed or mitigated.

This service scored 56 (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 had systems in place to promote learning when things went wrong, and staff were able to describe how incidents and concerns were reflected on within the team. For example, staff told us incidents were discussed in meetings so learning could be shared: “We talk about what happened,so everyone knows for next time.” Records showed the registered manager reviewed events such as accidents, hospital admissions and safeguarding concerns, and shared outcomes with the team. However, although learning processes existed, they were not always effective in improving the quality of people’s care planning or risk assessments, which limited how well these processes prevented repeated issues.

The service had procedures for assessment, referrals and care coordination, and staff were able to describe how they communicated changes in people’s needs. Staff told us they reviewed daily notes and care plan apps to understand updates before starting shifts. One staff member said, “We check the app and ring the office if something isn’t clear.” Professionals such as social workers and hospitals were involved when people moved between services, and staff described accompanying people to appointments or following hospital discharge instructions. However, because care plans contained gaps and contradictory information, safe systems were not always underpinned by accurate, reliable documentation, which limited consistency. Following inspection feedback the provider took action to remove historic information from care records.

Staff had a clear understanding of safeguarding and were confident recognising and reporting concerns.Staff were able to describe examples, such as noticing unexplained bruising and escalating thisimmediately. A staff member told us, “If someone is in danger, I call 999 first, then report it straight away.” Safeguarding was included in induction, refreshertrainingand ongoing supervision. The service reported incidents to external agencies appropriately.

The provider did not involve people effectively in identifying, understanding or managing risks to their safety and wellbeing. Risk assessments were frequently absent, in complete or inaccurate, and did not support safe decision making. For example, care plans for personal care, eating and drinking, continence, mobility, and medical procedures lacked essential detail despite staff delivering this support daily. One child required support with eating soft and bite sized foods, but there was no risk assessment or care plan associated with this to guide staff as to how to offer the support safely. Following our inspection feedback, the provider took action and put the relevant guidance and documentation in place for this child.

Another person used a hoist and ‘sarastedy’ aid, yet their mobility plan contained no instructions as to how to use the hoist safely and no explanation of safe manual handling techniques.
Information in people’s records was often contradictory. One child’s nutrition records showed multiple feed volumes and conflicting percutaneous endoscopic gastrostomy (PEG), feeding nasogastric (NG) descriptions. Following the inspection, the provider updated the child’s records to clearly show their current needs. A person’s communication care plan was over due for review and continence and nutrition risk assessments were missing for people receiving these types of support. Relatives told us people had not had a risk assessment since they started the service despite significant ongoing health needs.

Another example meant potential risks were not always identified early or recorded in a way that ensured preventative action. For example, nutrition and hydration needs had not consistently been assessed or recorded despite the person requiring support with this.

These shortfalls meant people and relatives were not enabled to understand or participate in managing their own risks. Staff made decisions based on their own judgement rather than following clear, personalised plans.
 

Staff ensured people’s environments remained uncluttered and free of immediate hazards, and people told us staff were mindful of safety in their homes. Staff described checking for trip hazards, lighting issues and unsafe equipment.A member of staff said, “I check wires, floors and the heating before I start.” Environmental risk assessments were completed, although some ratings did not fully reflect identified risks. For example,staff recorded‘no risk’ despite a person using oxygen or identified fire risks. Failure to effectively record known risks reduced the effectiveness of environmental risk assessments.Despite this, no concerns were identified around environmental cleanliness or immediate safety on the day of inspection.

There were concerns about the recruitment and verification of staff suitability. Several personnel files contained missing employment history, unexplained gaps, inconsistent dates and incomplete references. For example,a staff file showed inconsistencies between the dates of a staff members application and their CV, and others lacked evidence of interviews or reference checks. Some staff had no documented verification of their most recent healthcare employment. Following the inspection the registered manager took action to address the identified shortfalls.

There were inconsistencies about whether there were enough staff.People told us they felt there were enough staff available and calls were usually on time.However, a relative told us staff were often late when collecting their child from the day centre. Staff confirmed there could be delays when traffic issues occurred.

Staff said they felt supported and received an induction and ongoing supervision. However, weaknesses in recruitment documentation meant the provider could not demonstrate all staff employed were safe and fit to work.

Staff followed Infection Prevention Control (IPC) procedures, wore appropriate personal protective equipment and disposed of it correctly. People reported staff consistently wore gloves and aprons,“They always wear PPE and dispose of it properly.” Staff described hand washing, safe disposal of waste and equipment cleaning procedures. IPC information was visible in people’s care plans and daily notes.

Where the service was responsible for medicines, people received their medicines as prescribed. Staff were trained and described following safe practice. Staff checked people’s medicine administration records, dosage and the 6R's of administration. The 6R’s of medicine administration are a safety framework used in health and social care to reduce medication errors.

The provider completed monthly audits and no medicine errors were identified. Where people’s families managed their medicines, staff were clear about their roles and documented what they observed. However, inconsistent care plans and contradictory clinical information for some children created potential risk where clinical monitoring was required alongside medicines. For example, the enteral feeding guidance for one person contained unclear and contradictory guidance for staff. Following the inspection, the provider updated the child’s records to remove contradictory information.