Archived: LLOYDS CARE GROUP 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 requires improvement. At this assessment the rating has remained the same. 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 provider was in breach of regulation in relation to safe care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff consistently told us they were supported to learn lessons when things went wrong and were confident incidents would be actioned by managers. Staff said learning lessons was done through a variety of methods such as retraining, practical demonstrations and team meetings. The provider had policies in place to support people and staff when an incident arose. However, paperwork and actions taken were not always completed or documented fully. Where incidents had happened, follow up actions did not clearly show an outcome or how future risks had been mitigated. We raised this with the registered manager who said they would review their quality monitoring processes.

The provider did not always plan and organise care and support with people, together with partners and relatives and ensure this was documented for continuity and as guidance for staff. The registered manager explained information from partners was reviewed prior to delivering care to any new people however care records did not evidence this clearly. For example, where a person required support with a specific health condition and a weekly report compiled for other professionals involved to ensure the person’s safety, there was no guidance in the person’s care record to state this or guide staff on how or where to report the information to. This placed the person at risk of harm.

People and other professionals who worked with the service told us the provider worked with them to understand what being safe to them meant and the best way to achieve this. However, care records did not reflect these actions or give clear guidance for staff on how to support people to remain protected from abuse, neglect and harm. The provider did not always share concerns quickly and appropriately. While we saw evidence of safeguarding concerns being raised to the local authority these concerns were not always shared with the CQC as required. For example, one person was at risk of abuse, and while the staff had contacted the local authority and police to ensure the person was safe when incidents happened the provider had not notified the CQC of the concerns. Additionally quality monitoring records did not identify these concerns or record the actions taken by staff and management.

People we spoke with told us they felt safe with staff. Staff we spoke with demonstrated an understanding of how to manage risks by thinking holistically about how best to meet people’s needs and how people communicated their needs. However, care plans did not contain the level of detail described by staff or guidance to ensure people remained safe. For example, where people may need support with specific health conditions such as epilepsy and Parkinson’s, care plans had not been created to support staff in the event of emergency or to help staff identify symptoms of people’s condition deteriorating to ensure medical treatment could be sought. Early detection and timely intervention can significantly improve outcomes by initiating appropriate treatment at the right time and place, reducing the risk of serious harm, and potentially preventing hospital admission.

Although the maintenance of people’s homes was outside of the providers control, care records contained details and information on how staff could remain safe in people’s homes. However, where people used equipment to support their care within their own home such as bed rails or wheelchairs, care plans did not contain risk assessments to ensure people and staff remained safe whilst using the equipment or whether the equipment was suitable for the person’s home. Bed rails can pose a risk of entrapment, where a person's body can become trapped in gaps between the rail, bed, mattress, or headboard. This meant without clear risk assessments people were at an ongoing risk of harm.

The provider worked hard to ensure they had enough skilled and experienced staff to meet people needs and ensure they received their care support visits and remained safe. However, at times this action was in direct conflict with the working time directive for employees. Staff are required to have certain rest periods during an allocated timeframe, defined in the working time directive as 48 hours of uninterrupted rest within every 14-day period. Staff rotas and call time audits showed multiple incidents of staff working more than this requirement, sometimes up to 33 days without a rest break. The registered manager confirmed that they were aware of this when the assessment team raised the concern and stated they were recruiting additional staff to prevent this happening going forward. This placed people at risk of harm from staff fatigue.

The provider had recently had their sponsorship licence revoked which had enabled them to employ overseas workers and were supporting staff to find alternative employment whilst recruiting new staff to fill these vacancies. The registered manager had acted on feedback received during this process and recruitment records for recently employed staff were completed safely ensuring all required checks such as references and background checks had been undertaken prior to staff starting employment.

People told us staff used personal protective equipment (PPE) appropriately when they received support with their care. Care plans detailed guidance for staff about reducing the risk of infection with methods such as hand washing. The provider had an infection prevention and control policy in place that was available to staff as needed.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people required support with timed medicines to prevent symptoms associated with their condition developing or worsening on a daily basis, however the provider failed to ensure this need was met. For example, a person required medicine within 30 minutes of a specified time each day, records repeatedly showed this person received their medicine up to 2 hours after this specified time. This placed them at risk of harm.

Where people had a medicine allergy these were not always specified or recorded within care records. One person’s care plan stated they were allergic to a medicine, however no further details were provided about which medicine, and no guidance was given to staff on how the person reacted should an allergic reaction occur which placed the person at risk of harm. Staff did not use medicine administration record (MAR) charts consistently to show when medicines had been given or refused. The registered manager acknowledged they were aware of this concern but had taken minimal action to address the concern. These risks remained on the providers latest medicine audit meaning improvements had not been made and lessons had not been learnt.