Archived: Initial Care Services South East 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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment and the ways people’s medicines were managed safely at the service and the recruitment of staff.

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 did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

At our last inspection, we found that the registered manager did not always identify where lessons could be learnt. At this inspection, we found this had not improved. Since the last inspection the registered manager told us that there had been no incidents, and no safeguarding concerns. However, we found within staff meeting notes that there had been a safeguarding concern. The registered manager had not learnt from the previous inspection and did not ensure that incidents of concern were robustly recorded and addressed. The registered manager did not ensure that the person’s care plan was updated following the concern and that there was relevant guidance for staff to follow.

When incidents of concern were identified, there was no evidence of what actions had been taken to keep people safe and learn. The section for ‘lessons learnt’ on the providers safeguarding log had no information, despite there being 3 incidents of concern.

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

At our last inspection we found that there was not effective systems and processes in place to ensure that people would receive the support they needed if their needs changed. There were also not effective processes to ensure continuity of care throughout people’s care journey. At this inspection we found this remained the same. The registered manager told us they did not have information available to share with other organisations to inform them of people’s needs, healthcare conditions or communication. The registered manager confirmed that people did not have hospital passports to share for example, if a person was to go to hospital. The registered manager told us they relied on people’s family to provide information to other organisations.

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 share concerns quickly and appropriately.

At our last inspection we found that the registered manager had limited understanding in relation to safeguarding. At this inspection we found the same concerns. When a safeguarding concern had been identified the registered manager raised this with the local authority but did not take any actions to mitigate risks or ensure that there were relevant care plans or guidance for staff to follow. The actions the registered manager did take when concerns were raised demonstrated their lack of knowledge in relation to safeguarding people. For example, when allegations were made, the registered manager called the alleged perpetrator which could have put people at risk of further harm. Not all staff we spoke with were aware of how to raise concerns outside of the service, which posed a risk of a closed culture.

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.

At our last inspection, we found that the registered manager failed to recognise, review and mitigate risks to people. At this inspection we found this had not improved. The registered manager had failed to ensure that staff had the guidance and risk assessments in place to inform them how to support people with their complex health conditions including diabetes. Staff we spoke with did not all have a good understanding of people’s needs, or how to support them with complex health conditions including diabetes. One person was taking a medicine to reduce their risk of strokes and heart attacks. The registered manager confirmed there was no guidance in place to inform staff how to support the person with this, or actions to take if the person became unwell.

Other guidance was not in place to inform staff how best to support people with known risks. This included actions to take if people were to raise concerns, or where people had a history of making allegations. There was no guidance to inform or support staff should an allegation be made. The registered manager told us that these risks were historic and no longer relevant, but we found 2 incidents had occurred within the last 12 months.

When we shared our concerns with the registered manager, they put guidance in place to inform staff how to support people living with diabetes. However, they did not share how this information was shared with staff, or how they checked staff understood and could implement the guidance.

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

At our last inspection, we found that the registered manager had not appropriately assessed risks to the environment to ensure the safety of people and staff. At this inspection we found the same concerns. Although the provider told us they completed checks on the environment, the previous two care plan reviews noted no changes or updates in relation to risks to the environment. There was limited information about how the registered manager assessed risks to people and staff, and any care plans or risk assessments implemented as a result.

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.

At our last assessment, we found the registered manager was not documenting supervisions with staff. At this inspection, we found that supervision were taking place, however the quality of the supervision was poor and repetitive.

Staff had completed a series of training; however, the provider had not completed robust competency checks to review staff practice. Competency checks on medicine, moving and handling were not completed. Some areas of the competency checks reflected that the registered manager told staff how to support people, for example with their nutrition and hydration as opposed to observing their competency and being assured staff were providing effective care. When competency checks were completed, in one instance they were completed 2 years after the staff member started working for the service.

Staff had not been recruited through safe and effective recruitment processes. The registered manager failed to ensure that gaps in work history were reviewed and explored. Following the inspection the provider told us they had retrospectively completed this.

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.

Staff told us they had access to personal protective equipment (PPE) and used it when supporting people. The registered manager told us that they spoke regularly with staff, replenished PPE, and encouraged staff to use PPE when supporting people. Staff had been trained in infection prevention and control.

The provider was not clear on the level of support people needed with their medicines. They told us that people did not need support with medicines, however their care plan detailed they needed prompting. Information within people’s care plan was not accurate, for example the current dosage of medicine one person was taking was not correct. This placed people at risk of receiving inconsistent or the wrong support with their medicines.

There was no formal system in place to record when people were supported with medicines for example a medicines administration record. When we shared our concerns about medicines oversight with the registered manager, they put a system in place to have oversight of medicines. However, the system had not been in place sufficient time for us to review its effectiveness.