Bluebird Care (Hull and Beverley)

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 and

safe administration of medicines.

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.

Lessons were not always learnt to continually identify and embed good practice.

The provider did not have an effective system to monitor accidents, incidents and safeguarding concerns.

Records were not always consistent and did not always detail any follow up action taken and the outcomes of these. Lessons from accidents/incidents were not always learnt or applied in practice. There was a lack of systems to record management reviews of these records to ensure lessons were learnt and to continually identify and embed good practice.

Assurances were given from the provider around systems being implemented going forward.

The provider did not always manage or monitor people’s safety to ensure current information could be shared with healthcare partners. People’s care records were not always reflective of their current care and support needs. For example, one person’s care plans lacked sufficient detail about equipment used when moving and handling. This meant care records were not always accurate and increased the risk of healthcare partners not having access to updated information, such as visiting professionals or emergency services, when required. However, due to the nature of the care package the provider had regular communication with the person and their relatives, and the service made sure there was continuity of care.

Safeguarding systems, processes and practices were not always reliable or appropriate to keep people safe. Improvements were required to safeguarding processes to ensure people's safety was maintained.

The provider did not have a system in place to clearly identify, and record safeguarding incidents. There was limited evidence of any themes, trends or lessons learned analysis completed from safeguarding events.

Where safeguarding incidents had been documented, we were not assured these were always managed effectively. For example, some safeguarding concerns had no confirmation of what

actions had been taken by the service including if the local authority had been made aware or if Care Quality Commission (CQC) had been made aware.

The requirements of the Mental Capacity Act (MCA) were not consistently met, and mental capacity assessments and best interest decisions were not consistently recorded. The provider offered immediate assurances around systems and processes to complete and record these decisions going forward.

Overall, people were protected from the risks of abuse because staff had been trained to safeguard them. Staff confirmed they had received training, and they understood how to raise concerns. Comments included “I am aware of the providers safeguarding and speaking up policies” and “Yes, I am aware, and I know how to spot and report harm and abuse.”

Risk assessments related to people’s health and safety had not been fully completed and lacked sufficient detail and guidance for staff to follow to help keep people safe. Although the provider worked with people and their relatives to understand and manage risks, the service did not always plan or record care to meet people’s needs safely. This included risks related to people’s health conditions including diagnoses of Parkinson’s Disease and diabetes, risks associated with paraffin-based creams and historical risks associated with people’s lifestyle choices. Care documentation did not provide staff with relevant information about risks or information with how to report concerns. We asked the manager to provide us with immediate assurances around these risks.

Despite this, care staff had a good understanding of people’s needs and some of the risks associated with these. Staff explained how they supported people during care tasks to keep them safe. A relative also confirmed this and told us staff had a good understanding of their family member’s needs, “They know what they are doing, I can only praise them in every way.”

The provider failed to clearly record in people’s care plans who was responsible for the maintenance of equipment in people’s homes. No information was available to staff relating to

general safety checks of equipment and how to report any issues they may have. The manager acknowledged this and said they would look to review and update care records accordingly.

We did see evidence the provider completed an environmental risk assessment within people’s homes during the initial assessment to check if it was safe for staff to carry out the necessary tasks.

The provider did not always ensure safe recruitment procedures were being followed to ensure staff were suitable to work with people who used the service. Appropriate checks were not always completed to ensure new staff were suitable to work with vulnerable people. The manager acknowledged this and took immediate action to address this for current staff members. They confirmed they would update their recruitment processes going forward. The provider did not always make sure staff received effective supervision and development. There were gaps in management arrangements for staff, such as overdue appraisal, supervision and competency checks. Mandatory training such as moving and handling, safeguarding and medicines were overdue for two staff members and training was not available to staff supporting people with specific needs including people on an end-of-life pathway and diabetes. The manager took immediate action and provided evidence during the assessment of actions taken, including confirmed dates for completion of appraisals, supervisions, competencies and staff training.

Staff told us they had received an induction which included training appropriate to their role which enabled them to do their job well, this included face to face training. Although we found gaps in management arrangements, staff reported supervisions and appraisals were meaningful and provided an opportunity to request additional support if required.

People supported by the service told us they were happy with the support they received from staff. One person said, “They are trained, I feel safe with [staff].”

The provider assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and were aware of the procedures to follow if any concerns had to be shared.

The provider had commenced infection control audits and observed staff followed best practice during regular home visits. This also included checks that staff wore the appropriate personal protective equipment (PPE). Staff consistently confirmed this and said they had no issues or concerns with this support. A staff member added, “PPE is available in people’s homes and if we are running out, we can collect more from the office.”

The provider did not make sure medicines and treatments were safe and met people’s needs. Medicines administration was recorded in an electronic record. Staff told us they received training in medicines and people confirmed they had support to take their medicines. However, people did not always receive their medicines as prescribed. For example, we found repeated occasions of when a person’s time-sensitive medicines had not been administered with the required 4-hourly gap, placing this person at risk of harm. Although there was no evidence of impact to people, we asked for immediate assurances from the manager around systems and processes to ensure people received their medicines as prescribed.

Information was also lacking for staff in care documentation around when to administer a variable dose of as and when required (PRN) medicines. We found one person’s care documentation did not accurately reflect their need for topical creams.

Whilst we did see evidence of PRN protocols in place, we saw no evidence these protocols recorded the effectiveness of the medicines. Systems and processes in place had not identified the need to seek advice around one person’s medicines when they were considered not required. We shared The National Institute for Health and Care Excellence (NICE) guidelines for managing medicines in the community with the provider during the assessment to ensure they were aware of best practice.