Akos Care 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. This is the first assessment for this registered service. This key question has been rated 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; the ways people’s medicines were managed safely and staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always 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 always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. The provider did not have a robust process in place to record, investigate, and identify improvements when incidents and accidents had occurred. We found that the provider had not maintained an incident and accident log in line with current best practice. However, staff confirmed that following safety events, learning outcomes and actions taken were shared with them to support learning and help keep people safe.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider worked with people and those close to them to establish their plan of care. The provider had completed an initial needs assessment before people started using the service. Information about people’s needs was documented within their care plans and was shared with staff to guide the delivery of care and support.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. Systems, processes and practices to protect people from abuse and neglect were not effective. Following safety events, investigations were not always thorough, and appropriate actions were not always taken to keep people safe. We found that safeguarding report forms had been completed by staff. However, these were not always completed in full and protection plans were not always put in place to keep people safe.
However, staff reported that they knew how to raise concerns and had undertaken safeguarding training to recognise the signs of abuse or neglect. People using the service told us they felt safe with staff and were aware of who to contact if they had any concerns regarding abuse or neglect.
 

The provider did not always work well with people to understand and manage risks. Where risk management plans were in place, these were not detailed enough to ensure staff had all the necessary information to deliver safe care and treatment to people. For example, the provider had not completed appropriate risk assessments for mobility equipment, including wheelchair, and specialist mattress. Additionally, appropriate risk assessments had not been completed for risks associated with skin breakdown, asthma, falls, and wound care, which are necessary to manage these risks effectively and ensure the safety and wellbeing of people using the service. This meant that staff did not always have the necessary information to provide safe care and support. We spoke with the registered manager, who told us they would update risk assessments where required to ensure people’s safety.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care. The provider did not ensure the regular servicing and maintenance of equipment or carry out environmental risk assessments to identify, manage potential hazards and promote a safe environment. We found no documented evidence of personal emergency evacuation plans (PEEPs). These are required to provide information on how to support individuals who may need assistance during an emergency evacuation, including people with disabilities or mobility needs. However, staff had undertaken training on fire safety to ensure they understood how to respond in an emergency.

The provider did not ensure staff were adequately trained, supported, or developed to maintain the necessary skills, qualifications, and experience for their roles. Staff reported that they had completed an induction programme before working independently. However, we found that for some staff, there was no documented evidence of spot checks, competency assessments, supervision or appraisal to assess their knowledge and skills. In addition, some staff had not received mandatory refresher training, and others had not received training that was appropriate or relevant to their roles. This included essential training required to meet specific care needs, such as diabetes.
However, the provider had completed a Disclosure and Barring Service (DBS) checks or Right to Work checks appropriately prior to staff starting their roles. A DBS check is a record of a person’s criminal convictions and cautions. These checks help employers make safe recruitment decisions. There were enough staff employed to meet people’s needs to ensure people get the care they need when they want it. People experienced continuity of care. They told us they were supported by a regular staff team, with care delivered through an agreed routine.
 

The provider assessed and managed the risk of infection. Staff assessed and managed the risk of infection. Staff told us they understood Infection prevention and control (IPC) policies and wore personal protective equipment, such as disposable gloves and aprons, to help prevent and control the spread of infection to people. People using the service confirmed that staff wore gloves and aprons when delivering personal care. Staff had completed food hygiene training to ensure that they understood how to handle, prepare, and store food properly to prevent illnesses.

The provider did not ensure that medicines were managed safely. There was insufficient oversight of medicines management in line with current legislation and guidance, and medicines were not always stored appropriately. Staff completed the medicines administration record (MAR) when administering prescribed medicines. However, we identified a high level of omissions and refusals in the MARs record for 1 service user. The provider did not implement measures to address these omissions and refusals, which were necessary to maintain safe medicine practices.
In addition, medicines were prescribed on an “as required” basis (pro re nata – PRN) for some people. We found that individualised PRN protocols were not in place where required to guide staff on when to administer these medicines and how to accurately record their administration. Furthermore, some staff had not received training in the administration of medicines and had not undergone regular competency assessments to ensure safe practice. For 1 person whose medicine required titration (the gradual adjustment of the dose to achieve the desired effect), there was no documented prescribing guidance or clear instructions available to staff to ensure it was administered safely. This meant the person was a risk of not receiving the required level of the medicines to meet their needs.