Care Staff Services Ltd

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 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, safeguarding, staffing, and fit and proper persons employed .

This service scored 31 (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 lessons were not learnt to identify and embed good practice.
There was little evidence that the cause of accidents and incidents had been investigated to help ensure actions would be taken to prevent recurrences. Analysis and monitoring of people’s emotional wellbeing did not provide any further information into causes, triggers or themes that would support more effective risk management.
The provider had not identified all potential safeguarding incidents and taken appropriate action in response. Staff told us they reported safeguarding concerns through their WhatsApp group, however, they were not informed of the outcomes. This did not demonstrate there was a shared learning culture embedded into the service to identify and learn from incidents. Furthermore, this indicated poor oversight, lack of effective incident/accident management and a failure to embed learning into practice.
We reviewed staff files and found regular supervisions, appraisals and spot checks were not in place for all staff. This demonstrated learning lessons were not effectively shared and implemented into staff learning to ensure people received safe care and treatment. Some risks were only addressed when raised by inspectors, not proactively identified and resolved by the provider.
 

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.

We reviewed pre-assessment information in people’s care records. The care plans and risk assessments created by the service did not capture all detailed information noted in these assessment documents. This meant people were at risk of not receiving personalised care/support because plans of care did not include details of their needs and requirements when transitioning into this service. One professional told us, “Care plans would benefit from stronger integration with external health professionals.” This put people at risk of not having continuity in care to safely meet their individual needs. People were at risk of being cared for by staff who were unaware of this information.
 

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 always share concerns quickly and appropriately.
While the people and relatives we spoke to expressed they generally felt safe with the staff caring for them, our assessment found care did not meet the expected standards. Staff had received safeguarding training but did always demonstrate they understood how to put their training into practice.
We found examples where staff had failed to recognise safeguarding concerns and had not taken appropriate action such as reporting these concerns to relevant external agencies. This meant some incidents had not been effectively investigated, and action taken to keep people safe . The registered managers also did not demonstrate they reported all safeguarding concerns as statutory notifications to the Care Quality Commission (CQC) without delay. Following our queries and escalation of concerns, the provider submitted notifications. Ho wever, these delays and omissions raise serious concerns about the provider’s compliance with safeguarding requirements and their duty to notify relevant authorities promptly.
For example, we found an incident where carers were observed covering cameras in a person’s home during a care call. We also found an incident where a person was administered as needed (PRN) sedative medicine 9 times within 15 days, including an instance where 2 tablets were given despite prescriber’s instructions to administer only 1. There was no evidence of medical review following this high usage, and no PRN protocol outlining how to manage such occurrences. We found at times this medicine was administered when this person was not experiencing any distress. Sometimes, this medicine was withheld based on their spouse’s assessment of their calmness, rather than their own consent or best interests. The provider failed to evidence people were safeguarding from chemical restraint and the least restrictive support was provided when required. The registered manager dismissed this issue as a duplicate entry before investigating further. This serious oversight was identified by CQC rather than by the registered manager or provider using their internal quality assurance .
 

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.
We found care plans and risk assessments lacked sufficient detail. For example, one person with epilepsy had general information about their condition but no personalised information regarding their seizure frequency or associated risks. Their care plan did not include critical details about the medicine required. We also identified from their medicine administration record instances where prescribed medicine was inconsistently administered.
Another person had a known risk of excessive water consumption resulting in an electrolyte imbalance. Their care plan and risk assessments failed to include this information which meant the risk was not safely managed or monitored. Furthermore, the daily notes demonstrated a lack of evidence of hydration monitoring during care calls. The registered manager stated fluid monitoring was the family’s responsibility, yet no formal agreement or documentation was in place that supported this. The failure to document and manage a known risk meant this person was at ongoing risk of avoidable harm.
We also received mixed feedback from people we spoke to. One person told us, “The carers are very young, if anything happens, I don’t think they would know what to do ”.
Furthermore, one professional told us, “Care plans often lack sufficient detail and do not always reflect or cross-reference these risks. There's a recommendation to introduce condition-specific care plans e.g. for diabetes or dementia.”
 

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.
The provider failed to evidence risk assessments of people’s homes were completed to ensure the safe delivery of care.
For example, the assessments failed to consider risk factors such as the external environment of the person’s home, fire management, and risks associated with utilities and the potential need to isolate these in the event of an emergency.
One person with a known risk of serious harm to themselves did not have a risk assessment in place to mitigate this. This meant the provider/registered manager did not clearly identify and mitigate these risks so that all staff were aware of before providing care.
 

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. They did not work together well to provide safe care that met people’s individual needs.

We found a newly recruited carer had administered medicine and supported a person with moving and handling before any recorded competency assessment. This meant people were at risk of avoidable harm by being supported by staff required training and had not completed their competency assessed of skills and knowledge.
The provider was unable to demonstrate staffing levels, skills, and deployment were reviewed and adapted to meet changing needs, and if any tool was used to determine safe levels of staffing.
The service supported many service users with complex health needs such as diabetes, epilepsy, catheter care needs. We spoke to staff regarding people they supported. None of these staff could identify key health conditions affecting the people they supported, other than general references to ‘dementia’. This meant people were at risk from being supported by unsuitable, inexperienced and unskilled staff.
The provider did not demonstrate they operated safe, consistent, or transparent recruitment practices. There was no evidence staff were recruited based on a clear assessment of their qualifications, competence, character, and experience. We found references were frequently provided by existing staff or family members. Many had no relevant employment history, and some were entering the workforce for the first time. The provider did not demonstrate how these staff had the skills, qualifications, or aptitude required for their roles, nor how this was assessed prior to employment.
We found job roles and responsibilities were unclear and inaccurately documented. For example, one internationally based remote worker applied for a ‘Compliance Admin’ role but was issued a contract identifying them as a ‘Health Care Worker’. The lack of oversight and support for international staff meant there was no assurance that care decisions made out-of-hours or remotely were safe. This meant people’s care was being influenced by individuals who may not be adequately qualified or competent, without a system of accountability.
 

The provider assessed and managed the risk of infection. People told us care workers used personal protective equipment (PPE) when supporting them. No concerns were expressed about how infection control was managed in people’s homes. The registered manager told us they sought feedback from people regarding infection, prevention and control.

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.
There was a lack of guidance and body maps for people using topical medicines. This increased the risk of medicine errors or adverse reactions. Furthermore, some people were using flammable topical medicines such as ibuprofen gel. The provider failed to ensure appropriate risk assessments were in place to identify associated risks and mitigate these for people’s safety.
As needed (PRN) medicines did not have detailed protocols in place to ensure the safe administration and monitoring of medicines. For example, one person was prescribed a spray for cardiac symptoms. There was no as needed (PRN) medicines protocol in place for this medicine to ensure staff had accessible guidance on when and how to administer, monitor its effectiveness, or seek urgent medical assistance. This placed the person at risk of being unsupported with any cardiac issues in a timely way.
The provider failed to ensure medicine was always administered safely and in line with prescriber’s guidance. We reviewed people’s medicine administration records (MAR) and found staff had administered an overdose of a controlled drug medicine to 1 person. This had placed the person at risk of harm. Furthermore, this MAR was altered retrospectively; meaning the accuracy and validity of people’s MAR charts were not maintained or reliable to ensure any investigations could be completed effectively.
We found people’s medicine were not always administered in accordance with the prescriber’s directions. For example, one person experiencing active seizures was prescribed a medicine for epilepsy. However, we found this was missed multiple times without a justified reason recorded. This had placed the person at risk of harm.