JADE Healthcare Services

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 home care 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. We have asked the provider to take action to address the concerns found.

This service scored 53 (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. Lessons were not always learnt to continually identify and embed good practice.

Incidents, accidents and complaints were not always documented which meant the provider could not be assured they had identified patterns, learnt where things went wrong and had taken appropriate action to mitigate risks to people. This meant people were at risk of reoccurrence of harm or poor quality of care.

We found limited evidence of lessons learned being implemented to improve care, where shortfalls had occurred. For example, the provider carried out a service user feedback survey to assess the satisfaction of people and their relatives with the quality and safety of the service. The provider had created an action plan from the feedback obtained from people to improve service provision; however, this action plan had not been implemented and therefore the culture and quality of the service could not be effectively audited and changes implemented.

All staff were clear about how to report concerns. Whilst staff had confidence in the provider, we did not see evidence the provider did this well, as evidenced above.

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. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not always document assessments following people’s discharge from hospital. The provider shared information via an electronic staff messaging system when there were changes to people’s care needs. However, people’s risk assessments were not always updated to reflect these changes. This meant staff were not provided with clear written guidance to follow regarding peoples care and support needs. This meant, people were at increased risk of harm. We raised this with the provider, and they assured us they would review all care plans to ensure they were accurate.

Processes in place did not always ensure risks to people were monitored and managed safely. This involved not sharing information or requesting support from relevant external agencies to ensure best practice was followed. For example, we found people who lived with diabetes did not have related care plans in place. There was no evidence or documentation from relevant healthcare professionals with detail on who to manage the condition, or who to contact if there were any concerns. The lack of specific risk assessments meant staff had no guidance to ensure they could support people safely. This placed people at risk of harm.

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.

Documenting and recording of safeguarding concerns was not thorough and effective. The registered manager did not take appropriate actions to contact the local authority safeguarding team. This meant people were left vulnerable and were at risk of ongoing harm. For example, we found a person to have skin damage, however there was no specific care plan for managing the skin, or what staff should look out for. Daily records did not include details of where care should monitor the skin damage. Due to the lack of recorded information, we were not assured this had been reviewed and analysed or reported to the local safeguarding team.

People were supported by staff who were committed to keeping them safe and were aware of how to escalate concerns. They were aware of the signs of abuse and what to do should they recognise these.

The provider had a safeguarding policy in place, which detailed types of abuse and who the designated safeguarding lead was within the organisation.

Staff were able to demonstrate an understanding on the Mental Capacity Act 2005 (MCA); however, there was limited documentation in place to show the MCA had been considered when care plans and risk assessments were formed. This presented a risk of unlawful care and support being provided that did not reflect people’s wishes and best interests.

Staff knew how to report their concerns and were knowledgeable about safeguarding processes. Staff we spoke with showed a clear understanding of safeguarding process and signs of risks and abuse and were confident in raising concerns with the Registered Manager.

Staff told us there were regular meetings where important information was shared.

The provider did not always work well with people to understand and manage risks. Lessons were not always learnt to continually identify and embed good practice.

Care plans and risk assessments did not always reflect the risks to people’s health and safety. This meant staff did not always have sufficient guidance to provide safe and effective care. For example, we found people did not always have care plans and risk assessment in place relating to skin integrity, dietary needs or diabetes. We also found incorrect information in care plans. This meant people were at risk of harm of not receiving safe care to manage their known risks. People were not provided with opportunities to be involved in discussions about how they wanted their care provision to reduce and manage any risks to their safety.

Daily logs of the care tasks completed by staff showed elements of care were being provided. However, due to the lack of detailed records, we were not assured staff provided all care and support that people needed. This meant people were at risk of receiving incorrect care, placing them at risk of harm.

The provider did not always detect and control potential risks in the care environment.

There was a lone working policy in place as well as an environmental risk assessment policy and procedure, which stated a risk assessment of people’s homes should be completed before care started. Records showed these had not been completed, placing both staff and people at risk of harm.

Staff understood their responsibility to support people to maintain a safe environment. However, the provider failed to carry out regular environmental risk assessments of people’s homes and the equipment in use. For example, moving and handling equipment had not been regularly checked to ensure the home environment and the equipment used during the delivery of personal care was safe and fit for purpose. Care plans also stated that staff should check mattresses were in good condition and at the right setting, however there was no evidence that this was being carried out. This meant people were at risk of harm due to the possible use of faulty equipment.

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.

Evidence of Disclosure and Barring Service (DBS) checks were in place. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff felt they had the right level of training to carry out their role safely and effectively and received on-going support and supervision. Staff told us they received an induction before they started providing care to people. One staff member told us, “I did induction, firstly getting to the office, signing documents that required my signature completing my office file. Familiarising and reading policies. In the field I then did shadowing with senior members. The experience was very good and informative.”

We were not assured safe recruitment had been followed. Staff files contained conflicting information and lacked clarity. This shows recruitment and governance process were not robust or accurate.

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.

There was an infection control policy in place. Staff had also received training regarding infection control. This meant staff knew how to manage infection risk and reduce the spread of infectious diseases.

Service Users and staff told us that Personal Protective Equipment (PPE) was available, used and disposed of appropriately.

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

We reviewed medicines records and found times were not recorded for time specific medicines, or those which require a gap between being administered. Therefore, we could not be assured that this was taking place. This could lead to a risk of incorrect administration, or over administration of medicines due to staff not having clear documentation when medicines were given.

Care plans did not contain information regarding medicines, including what the medicine was for, when it should be taken or possible side effects. This meant care staff did not have details on what to look for when administering medicines.

Protocols were in place for the administration of PRN (as and when) medicines. These had dose and frequency of the medicine, as well as minimum time between doses. They detailed special instructions and possible side effects.

People we spoke with told us that they had confidence in care staff who supported them with medicines. Where staff were involved in handling medicines, people reported that it was given reliably and as required. One person told us, “They come in four times a day and they always remember to do it; there's never been any problems.”