Rift Solutions 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. 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 safe care and treatment.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. For example, we found staff were reporting and recording safety events; however, these were not always followed up by the office staff or management. Accidents and incidents were not always thoroughly investigated by competent staff and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result.

The provider did not always work well with people and healthcare partners to establish and 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. We found improvements were needed to ensure people’s care plans contained up to date information around areas such as continence care, skin care and support with medication. Risks to people’s health in some examples had not been assessed therefore mitigations had not always been put in place to reduce harm.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately. People mainly felt safe with the care and support provided by staff. Staff were aware of safeguarding processes and how to report concerns. We found that some safeguarding incidents that the registered manger was aware of, had been referred and investigated. However, there were some safeguarding incidents that had been recorded by staff on the system. These had not been captured by the registered manager, therefore these had not been actioned. Not all the required statutory notices had been submitted to CQC.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff knew people well, however, we found some improvements were needed to update people’s individual risk assessments and care plans. Comprehensive guidance was not recorded within people’s risk assessments and people told us they were not always involved in reviewing their care.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We found one person required the use of bedrails but there was no risk assessment in place specific to the use of the bedrails. We also found that the person’s care plan lacked detail in relation to the use of equipment, it was not identified which colour loops was required when using the person’s sling for transferring them with a hoist. The provider when carrying out an initial assessment completed checks and a risk assessment of people’s homes to ensure the environment was safe for staff to carry out their duties. Staff told us if they have any concerns in relation to the environment or people’s equipment, they would report this to the management.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs. Staff were recruited safely with the required mandatory checks carried out. Staff completed an induction and shadowed existing staff until they were comfortable to work unsupervised. As part of the induction staff had their competency assessed, however we found ongoing competency assessments for staff were not always completed as regularly as the providers policy stated. We also found some spot checks forms were not always fully completed or signed. We found on the training matrix some staff were not up to date with their mandatory training. Staff told us they felt they had adequate training and supervision. One staff member told us “Yes, the training is good, and we have regular supervision with [supervisor name].

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. The provider had an appropriate infection prevention control (IPC) policy and effective processes in place. The registered manager was clear on the IPC procedures required and their responsibility to provide personal protective equipment (PPE). During our assessment no concerns were identified with IPC, however, we found some staff were out of date with their IPC training.

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. We found that support with medicines was not always managed safely. Where people were prescribed ‘when required’ (PRN) medicines these did not have PRN protocols to support staff with identifying if these medicines were required. Improvements were required with the recording of administration of creams. We found staff were documenting in people’s daily notes that they were applying cream however they were not signing the medication administration record (MAR), to confirm the cream had been applied. We found that people’s medication care plans, risk assessments and MAR charts were not updated timely when their medication changed. We found one person’s controlled drug on one occasion had not been recorded on the MAR chart when administered and on another occasion the administered dose had not been recorded, however we did not find evidence of harm. Medication audits were not always completed as frequently as the providers policy stated and when they had been completed, they did not always identify issues identified during our assessment.