Lauriem Complete Care Limited - Ditton

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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.

At our last assessment we rated this key question Good. At this assessment the rating has changed to 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 and the way medicines were managed.

This service scored 53 (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 not always had a proactive and positive culture of safety based on openness and honesty. Although staff listened to concerns about safety, these were not always investigated and reported in a timely manner. Lessons were not always learnt to continually identify and embed good practice.

There was a system in place for staff to report incidents and accidents and staff told us they knew how to report concerns. People and relatives told us the care staff had a proactive approach to their safety and well-being. A person said, “I am more than happy with my carer. I am wobbly on my legs when showering and the carer stands near me, always a helping hand nearby if I feel I am about to slip.” A relative said, “A couple of weeks ago [relative] fell out of bed and the carer stayed with [them] until I got there and then the ambulance came.”

However, at the time of our inspection the provider had identified that not all incidents and accidents had been actioned in a timely manner by the previous management team. Lessons had not always been learnt following incidents and accidents for example people who had experience accidents did not always have their risks reviewed or updated. The provider was in the process of changing some of their internal processes to better support the management of incidents and accidents and had recently started to analyse their incidents and accidents to help drive continuous learning and improvement.

The provider did not always work well with people to maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider ensured that people’s needs were assessed before their package of care was delivered. A person told us, “I had someone from office visit to carry out risk assessment before the carers started. They checked out the hoist and asked how I liked to be supported.” A relative said, “We discussed at the start when the plan was drawn up, [staff] checked to see if everything was okay for us.” A professional told us, “In my experience, I have sent them the person's care plan, and they have arranged directly with the person being supported to complete the assessment. They then feedback their start date.”

However, the provider had not always maintained accurate records of some people’s needs throughout their time receiving care and support. There was a risk that people would not be supported to have continuity of care when they moved between different services.

Despite this, staff worked with healthcare partners to ensure people received care that met their needs during their care calls. A person told us, “Once I was feeling very unwell, I cannot remember anything, the carer tells me that I had called the ambulance, they stayed with me until the ambulance arrived."

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff understood safeguarding and knew their responsibility to report any concerns. Staff told us they were confident to do this and knew how to raise concerns externally too. A staff member said, “If I identify a risk, I report it to the office. If the office didn’t act, I would follow up with them. I haven’t needed to escalate further, but I know safeguarding or CQC could be contacted if necessary.” Another staff member said, “Safeguarding is the well-being of the client and making sure we report things when needed as per the training such as abuse.”

The provider had a log of safeguarding concerns and kept these under review. They ensured appropriate action was taken by staff. The management team worked in partnership with the local safeguarding team to support any investigations. A professional told us, “They support joint working and encourage joint visits when needed. For example, when a safeguarding concern was raised for someone, we were both supporting they ensured we did a joint visit together to try and provide support and investigate further. Their processes support this well.”

People and relatives told us they felt the service supported people safely. A person said, “I feel safe with the carers. I can have a laugh and a joke with [my] carer.” A relative said, “I feel I am able to leave [relative] in safe hands and go and do some shopping."

The provider had not worked well with people to understand and manage risks. People told us they had not had their risks or care reviewed in a long time; some people’s records had not been reviewed in 18 months. However, people felt involved in the management of their risk due to the positive interactions they received from staff. A person told us, “I can tell carers what to do. When they check my stoma bag I decide if it needs changing.”

Records we reviewed showed that not all risks for people had been assessed as required such as risk of skin breakdown. There were some people who were at risk of skin breakdown and had previously had pressure sores but there were no risk assessments in relation to this in their records. This placed people at potential risk of harm.

Some people’s needs had changed. For example, some people were no longer able to verbally communicate, and this was not risk assessed. There was a risk that staff unfamiliar with people would not know how to communicate with people to ensure their needs were met safely.

Some people had catheters (tubes in the body to drain fluid), stomas (an opening in the abdomen to allow waste to be collected in a bag outside the body) or Percutaneous Endoscopic Gastrostomy (PEG), (a feeding tube inserted into the stomach) in place. Although there were risk assessments in place in relation to these, risk assessments did not always highlight potential risks such as blockages or by-passing. There was not guidance about how to spot potential signs of infection. There was a potential risk that new or less experienced staff might not have the guidance required to support them to identify these risks. It is important for staff to have clear guidance on how to identify these concerns because concerns of this nature would need immediate staff attention to keep people safe from harm. Although there was no impact there was potential risk of harm to people.

Staff gave examples of how they managed risks. A staff member told us, “Recently, I identified issues with [person’s] catheter based on [their] non-verbal cues, escalated to the nurse, and it was resolved.” Records confirmed staff had recorded in people’s care notes when they had suspected issues with people’s catheters or stoma and these had been resolved.

Another staff member told us, “With pressure sore we report to our office for referral to nurse. We also have body maps that we complete and gives description of the sore; with permission we take pictures. Most clients agree and if in private area then we cover their dignity and just focus on the sore."

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider assessed potential risks for people in their homes and documented these in environmental risk assessments. This included areas such as safe use of people’s home equipment such as cooking or mobility equipment. A person told us, “[Staff] checked all the equipment was working correctly.” A relative confirmed for their relative, “[Person’s name] has a hoist, and all of the carers received extra training on how to use it correctly.” Staff told us they checked people’s equipment such as airflow mattresses or pressure cushions to ensure people’s equipment was safe and met their needs. Staff also told us they made sure people’s homes were left tidy. They locked doors and key safes and ensured people were wearing their lifelines when they left their homes to help keep people safe. The provider had not always assessed and mitigated the potential risk to staff from people’s bespoke equipment in their homes. We raised this with a manager who took immediate action to put this in place.

The service also assessed the risk of fire. This included a smoking risk assessment for a person where applicable and involved partner agencies such as the local fire department to help keep the person safe.

The provider did not always make sure their staff were effectively deployed to meet people’s needs. They did not always make sure staff received effective support and supervision.

People gave mixed feedback about the staffing of the service. Some people and relatives told us staff usually arrived on time and let them know if they were going to be late. A person told us, “99% on time. If held up with another client or traffic I get a phone call. No missed visits always somebody here.” Whereas other people felt staffing levels needed improvement. A person told us, “They are short staffed and sometimes I feel a bit rushed.” A couple of relatives gave examples of when staff had been running late or unable to deliver care calls and they had stepped in to provide the support themselves.

Some people told us that staff did not stay for the full duration of their allocated care calls although people and relatives said this had not negatively impacted on the care they received. The provider had been addressing with staff the need to document when people had told them nothing else was needed and to leave the care call early.

Staff also gave mixed feedback about the staffing. A staff member told us, “Calls are all covered plenty of staff and sickness is covered.” Whereas, another staff member said, “Not enough staff, not enough time and no travel time between and it has a knock-on effect for my day…If I had travel time I wouldn’t finish until midnight.” Some staff felt particular times had a greater impact on staffing levels. Comments included; “Most of the time, yes [there is enough staff]. During school holidays staff numbers drop, but we all step in and cover shifts, so no calls are missed.” And “The main issue is with double-up calls, especially at weekends and evenings.” Call monitoring records we reviewed supported people’s and staff’s feedback. The provider told us there had been some strain over the summer period but felt this had ended now.

Staff had been recruited safely. The provider carried out appropriate recruitment checks such as Disclosure and Barring Checks and seeking references. These checks help to assure the provider staff are suitable to support people. Staff had received mandatory training to help them carry out their roles however not all staff had received regular supervision. The provider was aware of this. They had reviewed their systems and processes and as part of their action plan had scheduled actions to improve staff supervision and support practices. We will review this at our next inspection. Despite this staff told us they mostly felt supported in their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and relatives told us that carers always wore personal protective equipment (PPE), and these were disposed of before they left and always changed soiled bedding and left the home clean and tidy. A person said, “Carers are very hygienic. As soon as they come in the wash and dry their hands and put on fresh gloves to examine by stoma bag. Before they make my breakfast, they put on fresh gloves.”

Staff were aware of how to mitigate and manage the risk of infection. Staff confirmed, “We have aprons and gloves, shoe covers and masks, and visors if needed. To prevent the spread of infection hand washing and PPE are strongly encouraged.” Staff also supported people to maintain their homes when needed to reduce the risk of infection.

Infection control practices were included in the providers observations of staff practice however the provider was behind their schedule on staff observations. They had plans to get these up to date.

The provider did not always make sure that medicines and treatments were safe and met people’s needs. For example, staff were leaving out medicine for a person to take later. The person was assessed as at risk of not taking their medicine appropriately, therefore there was a risk the person would not receive their medicines as prescribed although we found no evidence of harm.

We found another person’s medication record had not been completed accurately in relation to an ‘as required’ medication. It was unclear whether the person had received their medicines as required and whether there had been adequate stock. We asked the provider to look into this and take appropriate action.

The provider did not always have appropriate documentation in place in relation to the management of people’s medicines. For example, where a person required medication to be given via a PEG the appropriate documentation was not in place to demonstrate the service had received authorisation to crush and administer the person’s medicines. Authorisation is required from a healthcare professional to confirm the medicines are safe and remain effective to be administered in that form as it can change how a medicine is absorbed. The manager contacted the relevant professional and put this in place when we requested it.

The provider did not always have a record of people’s medicines documented within people’s care plans and ‘as required’ medicines did not always have relevant protocols in place as required. These records are important, to ensure staff have access to information and guidance about people’s current medicines and how to administer them. The provider took action following our feedback to ensure correct documentation was put in place.

Staff told us they had received required training and checks to administer medicines. A staff member said, “I administer medication. I’ve had training and the office does competence checks and spot checks.” Another said, “we do have regular medicines training which I think is really good.”

People and relatives were positive about the staff administering their medicines. A relative told us, “Yes, the carers do [relative’s] medication and there has never been a problem with [relative] getting [their] tablets when [they] should."