Jewel Home 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. At our last assessment we rated this key question inadequate. At this assessment the rating has remained 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.

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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

At this inspection we found the provider had not learnt lessons since the last inspection. Areas the provider advised had been rectified since the last inspection, were found to be incorrect, inaccurate or incomplete at this inspection, including high risk areas such as the safe management of anticoagulant medicine (blood thinners). This meant the provider’s actions had not been effective or sustained. This showed learning was not being embedded and safety concerns were not being addressed promptly or robustly. As a result, people remained at risk of serious harm.

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.

At our last inspection, the provider failed to maintain accurate records about people’s health conditions and support needs. The provider’s processes had not regularly monitored information to make sure risks to people were correctly recorded and managed to keep people safe.

At this inspection, we found people’s records continued to lack adequate information to promote safe, coordinated care and to support staff to deliver care consistently.

Where people lived with diabetes, care documentation continued to fail to identify who held overall responsibility for monitoring and oversight of people’s diabetes. For example, whether the GP or community diabetes team was responsible for reviewing and completing regular blood test monitoring.

The provider did not demonstrate safe pathways for escalation and review when people’s needs changed or when high risk conditions required specialist monitoring. This meant people were at risk of staff providing unsafe care and not escalating concerns when a person demonstrated signs of deterioration in their health condition.

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. The provider did not share concerns quickly and appropriately.

At the last inspection, we found people did not receive care which protected them from the risk of harm or injury. At this inspection, we found people remained at an increased risk of harm due to failures in record accuracy and care planning, which are fundamental safeguards in ensuring staff have the information they need to provide safe care.

Where risks were not correctly assessed or recorded into clear guidance, people were more vulnerable to neglect through omission, delayed recognition of deterioration by staff, or inappropriate response by staff. We identified significant concerns where a person had experienced a fall, whilst taking blood thinning medicine, and the risk of increased bleeding to the person had not been recorded as a risk.

The continued presence of inaccuracies and omissions in high-risk areas of care demonstrated safeguarding processes were not consistently effective in preventing harm, identifying emerging risks, or ensuring concerns were addressed promptly and comprehensively.

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.

Significant risks associated with long term conditions were not reliably identified by the provider prior to inspection activity. This was identified as a significant concern at the last inspection, and the provider told us they had taken action to make improvements in this area. However, following this inspection, significant concerns remained and some areas the provider said had been resolved and improved were still inadequate when we returned. These included risks related to epilepsy management, diabetic monitoring and escalation, and oxygen dependency with respiratory deterioration. Where care plans were introduced or updated, they did not always include the person specific detail staff required to recognise changes and respond appropriately, such as baseline observations, clear descriptions of how symptoms present for the individual, and clear escalation pathways. The lack of accurate, person centred risk management guidance meant people were exposed to the risk of deterioration going unnoticed or being responded to inappropriately, particularly in situations where rapid recognition and timely action were required.

We identified concerns in relation to incontinence pads, and staff ‘double padding’ a person. This was not the correct way to use incontinence pads, as using 2 pads increases the risk of Incontinence Associated Dermatitis (IAD) due to reduced breathability and too much heat building up. IAD also increases the risk of skin breakdown. This results in pressure sores, which can cause pain, discomfort and potentially serious risks to a person’s health.

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.

Whilst care plans detailed basic environmental risks, we found the provider had not put in place adequate smoking risk assessments, particularly for people who were prescribed, and using, emollient creams. The increased risk of ignition where emollient creams soak into clothing, bedding and soft furnishings had not been identified or risk assessed, which meant staff did not have clear, person-centred guidance to reduce this risk.

Following intervention from inspectors, the provider completed a smoking and emollient risk assessment for 1 person. The provider told us they would review all people using the service to identify who was prescribed emollient creams so the risk could be assessed and managed appropriately. However, it was of concern the provider did not already have oversight of this information. This meant we could not be assured all risks within the environment had been fully identified and mitigated for all people who may be affected, and there remained a risk of avoidable harm to people.

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.

We could not be assured about staff training and competency. The training matrix provided did not clearly describe the specific training completed across a number of areas. We requested further detail, which was not provided. This limited our ability to confirm staff had the right skills and knowledge to meet people’s needs safely. In addition, for people living with learning disabilities and autism, the evidence provided did not clearly demonstrate staff had received specialist training to support them appropriately as required by law. These shortfalls meant the provider could not evidence staff were consistently trained, competent and supported to deliver safe care across the range of complex needs being supported.

We reviewed staff recruitment files and found there had been an improvement in safer recruitment processes since the last inspection.

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.

Office staff demonstrated where personal protective equipment was stored and accessible to staff.

We found daily care notes contained examples of staff recording infection prevention actions, such as the use of gloves and aprons and changing gloves between tasks.

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 provider’s medicines governance remained weak, and improvements were not implemented in a timely way despite concerns raised at our previous inspection. Anticoagulant (to help thin the blood and prevent clots) risk assessments were not completed until after regulatory action was taken, despite the provider informing us these had been already been completedprior to this inspection. This meant there was no guidance for staff to follow if a person at risk of excessive bleeding was injured.

We also found continued inconsistencies between care plans, risk assessments and MAR (medicine administration record) charts. For example, daily care notes for 1 person referred to staff applying a prescribed cream, but there was no corresponding record of a prescribed cream detailed in the person’s care plan. In another example, staff were supporting a person to take a specific tablet due to difficulties managing independently, but this was not recorded in the care plan until the concern was raised during the inspection. When documentation was then updated, it introduced further confusion by prompting staff to administer and record medicines on a MAR chart which staff were not supposed to be administering. This put people at risk of receiving incorrect support with their medicines as records were not reflective of their prescribed needs.

Although the registered manager stated in previous actions plans they had oversight of medicines through auditing, the issues we identified had not been detected or corrected through those audits, including where weekly audits were being completed. This demonstrated medicines management processes were not sufficiently robust to identify and address medicines risks and documentation errors. This placed people at risk of harm from receiving medicines incorrectly.