Body&Soul Assistance, Admin.

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulations in relation to staffing and fit and proper persons employed.

This service scored 38 (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.

Records of incidents were incomplete and did not record what actions had been taken to reduce the risk of recurrence. Staff recorded basic notes in a book with no guidance on the information that should be documented. For example, following an accident in which a person sustained a burn from food served too hot, there was no evidence the provider had reviewed the incident or implemented measures to prevent a similar occurrence.

The provider lacked an effective system to share lessons learned or support staff development following any incidents or safety concerns.

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.

Systems to support safe pathways and transitions were not effective. Information about people’s needs was not comprehensively documented or shared, which increased the risk of inconsistencies in care delivery. The provider could not demonstrate robust processes were in place to support continuity of care when people’s needs changed or when information needed to be shared with staff and external professionals.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Systems and processes were not in place to support the safe management of safeguarding concerns. The provider did not have a safeguarding policy, and staff had not received up to date safeguarding training. This issue had been identified at the previous assessment; however, the provider had failed to implement the necessary improvements. We were not assured safeguarding events would be managed appropriately. However, people told us they felt safe.

The provider did not work well with people to understand and manage risks.

Risks to people’s health, safety and wellbeing were not assessed. There were no risk assessments in place. Despite significant risks being identified within care assessments, there were no related risk assessments to guide staff in areas such as moving and handling, skin integrity and bowel care. For example, 1 person required support with moving and handling using a hoist and a sling and regular repositioning, yet no documented guidance was in place to guide staff on how to do this safely. People required some complex care interventions and there was no evidence risks had been assessed to ensure staff had essential guidance to support people safely. Staff drove people’s cars as part of their role and no assessments were in place to manage this. The provider relied heavily on verbal instructions which meant staff were not provided with consistent and robust guidance to mitigate the risk of harm to people. This shortfall was highlighted at the last assessment, and no improvements had been made.

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.

Care and support was provided in the people’s own homes. There were no environmental risk assessments in place to guide and support staff to manage any hazards or risks. There was no evidence of safety checks on equipment. Where equipment issues were identified there was no evidence of robust follow up action. For example, an entry in team meeting minutes stated, 'slings are in desperate need of replacement' but there was no evidence to highlight what action had been taken. It was not clear how staff supported people to evacuate safely in an emergency.

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.

Recruitment was not managed safely. Records did not demonstrate appropriate interviews had been undertaken, and there was no robust system in place to obtain and verify satisfactory employment references. This was identified at the last inspection, and the provider had not made the required improvements.

Staff received an induction, but training records did not evidence robust regular training or competency led assessments. Some staff had been signed off as being competent by other care staff, despite there being no evidence those staff were appropriately qualified to assess competency. The provider had also deemed staff competent to undertake specific clinical tasks without being able to demonstrate they had the necessary up to date training to carry out this role. This increased the risk of harm to people.

Staff did not receive documented supervision or appraisal. The provider told us this was carried out informally on a one-to-one basis but there was no supporting evidence to reflect staff received ongoing support and guidance to carry out their role safely.

People received consistent support from the same staff. Staff did not raise any concerns about the support and training they received from the provider.

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.

Staff received verbal direction from the provider. However, records did not evidence the provider or staff had up to date training to ensure the risks relating to infection, prevention and control (IPC) were safely managed. The absence of documented procedures, including high risk aseptic techniques, meant we could not confirm staff understood or implemented safe IPC procedures.

Medicines were not managed safely.

Staff administered medication as part of their role. Records were basic and there were no medication administration records (MARs) in place. Staff recorded in a diary the date and time some medication was administered. People were prescribed medication ‘as required’ (PRN); however, there were no protocols in place to guide staff on when these medicines should be administered. Where medication was given, there were no records as to why the medication was administered or the result. These included medicines prescribed for asthma, anxiety and constipation.

People were prescribed topical medications and there were no documented records about how and when they should be applied, or records of application. One person’s assessment clearly stated the provider should ensure MARs and monitoring of medication should be in place.

Staff had not received any training or competency led assessments in the safe administration of medication, and there were no audits in relation to the management of medicines.

Whilst people were able to verbally make decisions about their medicines the required documentation was not in place to ensure safe administration and effective oversight.