Ideal Care Services - Kent

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. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safe and effective staffing and safeguarding people from abuse.

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 always listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems were not robust to ensure all incidents were reported or escalated by staff. Leaders had not reviewed daily notes to identify any incidents or accidents recorded by staff. We reviewed a person’s daily notes which identified a person had a small skin tear. Whilst staff documented this in the daily notes, no further action was recorded to understand how it occurred or if any medical assistance was required. The provider was unaware of this incident when we asked them during the inspection.

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 failed to ensure that risks to people were documented and known through their care journeys.

There was a poor awareness of the risks to people across their care journeys. For example, the provider told us that staff did not support with administering insulin to a person they support. However, we found this not to be the case and the staff were administering the persons insulin. Administering insulin is a delegated clinical task because it involves a high-risk injectable medication that directly controls blood sugar. The provider had not ensured effective guidance was in place for staff or sufficient oversight of the clinical task had been implemented, which placed people at risk of unsafe injection technique, or people’s diabetes not being controlled safely with significant changes in blood sugar levels not being acted upon.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not share concerns quickly and appropriately.

The provider had not implemented effective safeguarding processes to ensure people were protected from the risk of harm or abuse. Whilst some incidents had been reported to safeguarding, this was not consistent. For example, we identified a potential safeguarding incident within care records which had not been escalated. The provider was unaware of the incident that had been documented by staff. Following the inspection, we raised a safeguarding referral for this incident.

There was not a strong understanding of safeguarding and how to take appropriate action. Some staff were not on the training records and there was no evidence they had completed safeguarding training. Staff did not always understand their responsibility around safeguarding, for example, an incident was recorded in the daily notes, by staff, which detailed the person shouted out during their personal care to express they were unhappy with the care. They stated, they felt the staff member had used too much force. The provider was unaware of this record in the daily notes, and this had not been escalated by staff to ensure the incident could be investigated and appropriate action taken.

Staff we spoke with could not fully demonstrate their responsibilities around safeguarding, one staff member told us, ‘I would tell the manager, once I let them [registered manager] know it’s their responsibility’. They were not aware of their own accountability for how to raise safeguarding referrals if they remained concerned that people were at risk of abuse or neglect.

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 to people’s health were not assessed or mitigated. The provider had not implemented effective guidance to ensure staff could support people safely. For example, people who had epilepsy did not have robust support plans in place. The guidance was poor and did not detail that the person required emergency medicines to help manage their seizures. Staff recorded the seizures, however they had not recorded the length of the seizure or what action they took when the person had a seizure. This meant we could not be assured that prolonged seizures had been escalated for urgent medical advice as necessary to ensure people’s safety.

Guidance was not in place for people who were at risk of pressure injuries and ulcers. One person’s care plan detailed they needed to be repositioned regularly, without any further guidance. There was no information on how often and how staff needed to reposition the person, increasing the risk of them sustaining a pressure injury, which would cause significant discomfort and risk of infection.

Effective guidance was not in place for people that had respiratory health concerns. One person’s daily notes detailed they required support with nebulisers and ventilators, however their care plan did not contain any reference to this health need. When we asked the provider what this medication was prescribed for, they were not sure. There was no guidance in place for staff to follow to ensure they supported the person safely.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. People were supported in their own homes, and their care and support plans did not identify, or risk assess the equipment they required to ensure they were supported safely. For example, one person had a ventilator machine to support their breathing during the night. There was no reference to this in their care and support plan to inform staff of how it should be safely used. Another person required the use of a hoist to help them transfer, however there was no guidance for staff on how to use the equipment safely which placed people at risk of significant injury through incorrect use.

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 had not ensured that all staff were trained and competent to support people with their complex health needs. For example, one person required trained and competent staff to administer their insulin medicine to help manage their diabetes. The provider could not evidence that all staff had completed training and been assessed as competent to carry out this clinical task leaving people at risk of harm.

Staff we spoke could not demonstrate they fully understood people’s health risks and were competent to support them. For example, one staff member stated they couldn’t carry out Cardiopulmonary resuscitation (CPR) on a person because they had a tracheostomy. There was no guidance or information that detailed why they should not carry out CPR if the person stopped breathing. Cardiopulmonary resuscitation is an emergency life-saving procedure used when someone stops breathing or their heart stops.

Staff had not completed any training for supporting people with a learning disability and Autistic people. Since 1 July 2022, all registered health and social care providers have been required to provide training for their staff in learning disability and autism. This meant staff were not knowledgeable about the inequalities and challenges faced by people from this group, despite supporting people with these needs.

Safe recruitment processes were in place such as use of disclosure and barring (DBS) checks. These are checks against the police national computer to make safer recruitment decisions.

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 provider had not ensured that all staff had completed infection, prevention and control (IPC) training, some staff were not on the training matrix and therefore we could not be assured that all staff had completed IPC training.

Some people’s care plans contained basic information on their personal care or no information at all. Daily notes demonstrated staff were supporting people with personal care, however there was no guidance in place to support people to be consistently supported.

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 medicines that people took were not documented on their care plan to inform staff what medicines they took and any associated risks or concerns to be aware of. For example, one person was prescribed a blood thinner medicine, which increased the person’s risk of bleeding should they injure themselves. The provider had not implanted a risk assessment or guidance for staff in relation to this medicine.

Guidance for ‘as required’ medicines was not robust. One person was prescribed ‘as required’ insulin to help manage their blood sugar levels. There was no guidance in place on when to administer the medicine and what dosage would be required. We could not be assured people were being supported with their medicines in line with prescriber guidance.