Eureka Care Services Limited

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• 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.

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, staff training received, timeliness of care provided and keeping people safe from harm at the service.

This service scored 38 (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 did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

People gave mixed feedback about the registered manager’s response when they raised concerns. However, some of those people were quite clear that when they raised a concern, little was done to remedy it. One relative told us they raised a concern about the safety of an aspect of the care delivery. They said the registered manager was dismissive and did not listen to them or seek to review the safety. They said, “When we raised this concern, [registered manager’s] attitude was this is how it should be done and asked us to show them how it should be done.”

Incidents that occurred had not been reported to the registered manager for these to form the basis of lessons learned. For example, we were made aware of a choking incident that had occurred when staff were present. This had not been reported, was not documented in the care records or separate incident form. The registered manager when spoken with was unaware of this incident. Two safeguarding incidents had been raised for two people, both relating to poor techniques when assisting people to transfer. There had been no discussions, reflections or investigations involving staff to identify where practise could be improved to reduce the risks of further incidents.

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.

The provider cared for people on behalf of the local authority. Significant concerns had been raised around the quality and safety of care which was being delivered to people. People’s needs had not been fully understood, care plans had not been reviewed, and risks had not been escalated as required. For example, people living with dementia did not have risk assessments and plans to inform all staff how to support them. One person at risk of choking had not had this identified by staff and assessed along with another person whose significant physical needs had not been specifically assessed. These placed people at significant risk of unsafe and inappropriate care or support.

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 registered manager told us they had not been involved with a safeguarding incident for the past 12 months. However, care records lacked the detail required to adequately safeguard people from risk of avoidable harm or abuse. For example, one person’s relative told us how they had dysphagia, a condition that places people at increased risk of choking. Care records did not refer to modified diets and how to safely support this person. Key risks of not having a risk assessment included increased chances of preventable, adverse events like choking, infections, aspirational pneumonia and hospital admission. The systems operated by the provider did not ensure these known risks were assessed leaving them at risk of harm.

During this inspection, two safeguarding alerts were raised. Both related to poor moving and handling and concerns with personal care delivery. One person had been transferred by staff in an unsafe manner, which had been approved by the registered manager. They did not have the appropriate training to assess how people could be safely transferred using equipment. This placed people at risk of harm.

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.

People were not involved in understanding and managing risks. We found people and their relatives did not have regular care reviews that assessed identified areas of risk. For example, one person required support with their physical disability which had not been assessed or reviewed. People living with dementia did not have plans developed with them. Risks that were known to the registered manager and staff around areas such as refusals of care or anxiety when they were supported using a hoist, did not have plans to mitigate those risks that had been developed with people. This lack of engagement and review with people increased the risks that people may experience unsafe or inappropriate care.

People’s care records showed that known risks were not assessed or reviewed with people or their relatives. We were told by people and their relatives about existing conditions people lived with, for example dementia, cancer, dysphagia and physical needs, which had not been reviewed regularly. One person’s relative told us, “I haven’t really had one [review] since they started which is coming up for a year. If there are any changes I inform by email or text. My problem is the management and that where it starts. In all aspects of going back and talking to them they say they will do this and that, but it doesn’t happen. Our GP organised what [Person] needs through their social prescribing.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider told us they completed an environmental risk assessment in people’s homes as part of the initial assessment for care. However, when we asked for the records for people, we reviewed these were not provided. Monitoring processes lacked clarity about who was responsible for ongoing checks and how frequently these should be carried out.

There were not always enough staff, and the provider did not make sure they were appropriately skilled and experienced. They did not make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People did not always receive their care at the time planned. We looked at the visit logs and analysed 2270 visits. Of these 413 were later than15 minutes, and 30 were more than 45 minutes late.

Staff completed a broad range of training in areas such as safeguarding, mental capacity, moving and handling were covered and in date. However, where staff provided specialist support to people, they had not received training of a suitable level. For example, the registered manager told us staff supported people living with dementia, learning disability and physical disability. Staff had not had any training at a higher level to support their awareness. Although a training and development policy was in place, there was no mention of the staff’s requirement to complete learning disability training, including specific mandatory training on learning disability and autism, which is the government recommended training for all health and social care staff in England, despite this being a care specialism offered by the service.

Training records showed the registered manager, who was also responsible for assessments and care reviews, had not undertaken training to support that role. For example, they had not completed training at a sufficient level around assessing capacity, risk assessments and care planning or management and governance. We have found improvements needed in these areas which demonstrated how that lack of experience contributed to these improvements being required. Further to management training and development, training records showed that although staff completed most core modules, the registered manager had not. Areas outstanding included safeguarding adults, infection prevention and mental capacity awareness.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Feedback from people regarding infection control processes was variable. Some people felt staff worked in a hygienic manner, using personal protective equipment when providing care and protected people from the risk of infection. Other people said that staff did not all work in such a manner. A safeguarding had been raised relating to one example where a staff member had provided personal care to a person, did not remove their gloves and applied a lip balm without changing. This was not practise that supported good hygiene management. Not all staff had completed infection prevention and control training to support the delivery of good practise when providing personal care.

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.

Two people were administered their medicines by care staff. Medication administration records showed that staff administered these as prescribed and would support people to safely store and manage those medicines. However. protocols for the administration of ‘as and when required’ medicines were not in place. Medicine records did not always include the time people had been administered ‘as required’ medicines, which may lead to people being given an incorrect dose. Care records however did not show where people were involved in planning how they received their medicines and did not identify risks associated this task.

The provider was unable to provide us with evidence that competency assessments had been carried out to ensure staff who administered medicines remained safe to do so.