HK Care Consulting Limited

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 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 safe care and treatment.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and their relatives knew how to raise safety concerns, should the need arise. Relatives explained they felt the registered manager listened to any concerns they had and would take action.

Staff knew how to report a concern or an accident which had occurred.

Where an accident or incident had occurred, the provider completed a detailed review, and listed actions taken in chronological order. Where lessons had been learnt as a result, these were communicated to staff. One staff member said, “We have got the app [on their mobile phone] and everything goes on there.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People and their relatives found the referral process smooth.

A relative explained how the service had worked well with health professionals when the person had transitioned from children’s services to adult services. They also described how the initial introduction between the person and staff was done with family and in a relaxed environment or at a local activity the person enjoyed.

Another relative complimented the service on their approach to changes within the person’s care needs as they had become an adult.

The provider mostly worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us they felt safe and well cared for. However, we identified concerns around staff using the least restrictive support, and a lack of mental capacity assessments. This meant we could not be assured people were not unnecessarily restricted.

Staff had received safeguarding training and understood how to recognise and report potential abuse. The provider had a safeguarding policy in place.

The registered manager advised that whilst there had been no recent safeguarding matters, they were aware of how to report this should any arise.

People who displayed distressed behaviour were not always supported in line with their assessed needs and planned strategies to reduce distress.

For example, 1 person’s behaviour support plan stated staff should follow the assessed de-escalation strategies when they had become distressed. The record stated a sedative medicine may be given, but only as a last resort when all other interventions had been attempted and found to be ineffective. Staff were also instructed to complete a detailed form to describe the setting, how the person presented, and the strategies used by staff to attempt de-escalation.

We identified a number of days where the person had been given this sedative medicine, however no corresponding records had been completed. This meant there were no evidence of strategies which had been undertaken by staff in their attempts to deescalate the person’s distress.

This meant the provider could not be assured sedative medicine was being used only as a last resort and in accordance with the person's assessed needs. The absence of behaviour records limited opportunities to review behavioural triggers, evaluate the effectiveness of non-pharmacological interventions, and identify potential new triggers to reduce future incidents. This placed the person at risk of receiving sedative medication unnecessarily and without evidence that less restrictive interventions had first been explored.

The provider had considered and recorded other risks, such as mobility risks, and these were well detailed in people’s care plans.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider completed environmental risk assessments to ensure the safe delivery of care in people’s homes.

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.

Staff had not always been recruited safely. We found inconsistencies with a number of staff recruitment files including, conflicting information between references and the staff member’s employment history, some employment history not fully completed for other staff members, and a lack of evidence the provider had sought assurances as a different staff member’s conduct in previous employment working with vulnerable adults. This was not in line with the provider’s own recruitment policy.

Where staff had received supervisions, the record of these meetings demonstrated staff had primarily responded in short answers and there was no evidence of robust discussions to identify any issues and drive continuous improvement within the service.

The provider employed enough staff to meet people’s needs, and staff had all received training in a wealth of areas. Where required, competency assessments had been completed.

Relatives told us they felt staff were well trained, with 1 responding when asked whether staff were well-trained, “Absolutely I can't doubt or fault their experience.” Relatives also told us people received care from the same small group of staff, which meant the person got to know the staff.

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.

The provider had a plentiful stock of Personal Protective Equipment (PPE) which staff could access when required.

The provider mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People received routine medicines at the right time, from trained and competent staff members.

However, where people were prescribed sedative medicine to be given as required for distress, the instructions for staff on how and when to administer these lacked sufficient detail and did not link with other records for the person, such as a behaviour care plan. This meant if staff reviewed the information solely for the as required medicines, they would not be aware of alternative methods which should have been undertaken prior to the administration of the medicine.

Where people required a specific approach when staff administered medicines, this had been checked with the GP and confirmed in writing.

The registered manager completed regular medicine audits on the timeliness of routine medicines; however, the audit had not identified the concern around as required medicine.