Archived: Keiron Starns Care Agency

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 people’s safe care and treatment.

This service scored 59 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had an action plan in place which identified areas of improvement. This information was shared with staff. Staff told us that they communicated regularly within the team to share learning. We saw that the provider had communication systems in place to share learning amongst the team.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider spoke regularly with healthcare partners to ensure information was shared. We saw a quality assurance report was provided annually to commissioners of the service.

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. The provider had systems and processes to enable staff to safeguard people.

Staff had completed safeguarding training, and the provider had a clear safeguarding policy, which staff had access to. However, when speaking to staff they did not have a good understanding of safeguarding or the Mental Capacity Act. This meant the provider could not be assured all staff knew how to identify safeguarding concerns or take action to ensure decisions were made in people’s best interest. For example, we saw a person who lacked capacity with their finances had an accessible vehicle. The provider had authorised this vehicle to be used to transport other people at the service, at a fee of a set amount toward fuel contributions.

While the registered manager was transparent with other professionals about this agreement, they failed to identify that people were paying accurately contributing to the fuel they used. This meant that people were at risk of financial abuse. There were no records present to ensure that this decision had been made in line with the principles of the Mental Capacity Act.

However, people told us “I’m safe here”. Relatives told us “[Person] is definitely safe.”

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. This meant that that people could be at risk of harm. However, staff could talk about risks related to a person and what they did to mitigate these risks. Service users were able to explain some of their risks, how to mitigate these and how staff supported them.

The provider had identified a person using the service was at risk of choking. The person’s care plan contained details of how to support them safely and mitigate the risk and the provider had completed a risk assessment for this. However, the risk assessment was not individual to the person and did not include full instructions for staff in the event of a person choking. The provider had also not escalated this concern to the appropriate healthcare professional. This did not ensure the person had received a full assessment of the risk. We spoke to the registered manager who took immediate action and referred the person to the appropriate support.

Another example found on inspection found that risks related to a person’s diagnosis had not been identified and recorded. One person’s care record made reference to constipation. This had not been recorded in line with best practice. This meant people were at risk of harm.

The provider did not always detect and control potential risks in the care environment. However, they made sure equipment, facilities and technology supported the delivery of safe care. The provider completed health and safety checks of the environment and ensured servicing and maintenance of equipment such as boilers was regularly completed by a qualified engineer. The provider maintained a log of all maintenance issues and arranged for these to be rectified quickly. The provider had completed regular checks on fire equipment such as smoke detectors and the fire alarm system.

The provider had a fire procedure along with a fire risk assessment. However, the fire risk assessment had not been reviewed. This meant that the provider could not be assured new risks had been identified. Practice fire evacuations had been completed regularly. We found that one staff member had not been involved in these practice evacuations. The registered manager took immediate action at the time of our visit to ensure all staff had completed a fire evacuation.

However, the provider had not completed a simulation of nighttime evacuation. This meant that the provider could not be assured that the plan in place to evacuate during the night would be effective.

The provider made sure there were enough qualified, skilled and experienced staff. However, they did not always make sure staff received effective support, supervision, development or ensure that recruitment was managed in line with national guidance.

All staff had received appropriate training to perform their role safely. Staff told us they felt supported by the registered manager and received training that enabled them to work safely. People told us that they felt staff were effective. One person told us “[staff] know what they are doing” and “[staff member] is good”. Relatives told us they felt their relative was supported safely by trained staff. The provider had ensured all staff received an induction when first employed. Staff had received annual appraisals. However, the content of these did not contain new information or information to support staff development.

Supervisions were completed for some staff. However, the frequency of these were not in line with the provider’s policy and did not contain clear details of conversations or actions. Further, references for all staff had been obtained. However, one reference did not contain a start date. We saw that full application forms were not in place for all staff members. This meant the provider could not be assured that staff had been recruited safely.

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 infection prevention policy. However, the policy required updating to ensure that best practice guidance was included.

Staff had received training in infection prevention control and Covid-19. Staff told us they had access to personal protective equipment such as gloves and aprons. They were able to describe how and when they used this and how to dispose of it safely.

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 their medicines.

The provider had a medicines policy which gave guidance on administering medicines and staff had completed medicines training. Medicines administration records were completed in line with national guidance and medicines were stored safely.

The registered manager checked medicines had been given each time they visited the service and completed a monthly count of the medicines. However, no audits were completed and recorded. Further, staff competency to administer medicines had not been assessed. This meant the provider could not be assured errors were identified or that medicines were administered safely or in line with national guidance.

Care records did not contain guidance on how people liked to take their medicines. All medicines were stored in a designated room and the registered manager told us that people had to take their medicines in that room. People were not asked how they would like to take their medicine or where. This meant the provider failed in offering choice and control to people or supporting them in a way they preferred.