Living Glory Social Care

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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service remained in breach of 4 legal regulations in relation to safe care and treatment due to inadequate care planning and risk assessing and unsafe medicines management; protecting people from abuse and harm; staffing; and fit and proper persons employed at this service.

This service scored 28 (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.

The culture within the service was not focused on improving safety and learning. Since our last assessment there had been little improvement in the guidance for staff in relation to known risks to people. Further information for staff was needed about how the risks would be managed. Although there was now a system in place for recording and analysing incidents, this was not robust. This meant there were missed opportunities to drive improvements in the service from lessons learnt in relation to incidents which occurred. For example, where safeguarding alerts had been raised, there were investigations, but no detailed analysis of how such events had occurred, or robust actions implemented to reduce the risk of reoccurrence. Where actions had been identified such as staff training these had not been completed in a timely way.

Staff supervisions were not carried out robustly to aid improvements in the service and safety of people with complex support needs. Where events and incidents had taken place there was a lack of evidence learning from these had been shared with the wider staff team.

Where complaints or compliments had been received, the analysis and actions taken were not always robust and we saw similar issues such as late or missed calls continued to occur.

People and relatives told us they could contact the service if they had any concerns about their care.

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.

Records held by the provider failed to demonstrate there was adequate information for robust continuity of care, including when people moved between different services. This included when people transferred to hospital due to their health conditions having deteriorated. The provider failed to maintain comprehensive records of the care and support provided by staff and the auditing of such records, ensuring records and subsequent actions were clearly documented and carried out.

Although there were support plans in place which had been uploaded to the provider’s electronic system, we found about of half of these were not visible to staff to refer to should they need guidance. This was due to the provider choosing not to allow to staff to view these electronically whilst awaiting consent from people using the service. The provider told us there were paper copies of support plans in people’s homes; however, some people and their relatives told us they did not have these in their homes. The provider had not taken into consideration the implications of staff not having access to this information online.

The provider had completed pre-assessment paperwork; however, these documents lacked significant information in relation to the support people required.

The provider did not consistently 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 the provider failed to recognise what safeguarding meant and had not recognised or responded appropriately to potential abuse. They failed to carry out robust investigations into these incidents and make appropriate safeguarding referrals to protect people from abuse. At this assessment the provider continued to fail to recognise potential abuse, protect people from potential harm and notify relevant others of such concerns. For example, where calls were missed for 2 people, these were not reported to the local authority’s safeguarding team and measures put in place were not effective to ensure this did not occur again. For another person who was at increased fire risk due to smoking, the provider had failed to escalate and seek further advice and put appropriate measures in place to ensure the person’s safety. This incident could have caused significant harm or even death, because guidance for staff to follow was not in place. We found a lack of guidance for staff on the management of known risks was the case for at least 7 people using the service. We raised safeguarding concerns due to the lack of systems to keep people safe. The service failed to share concerns appropriately with relevant agencies, teams and professionals which was confirmed by the local safeguarding team.

Incident records we viewed did not consistently include details of the method of restraint used, duration or location of the restraint. This had not been identified by the provider and did not evidence appropriate approved restraint techniques were being used by staff and for no longer than necessary.

Most staff members employed had received training in safeguarding and could tell us what safeguarding meant. However, 1 staff member told us if they witnessed an inappropriate incident by a family member in the home they would not interfere. They said, “I would ignore it as it is a personal thing.” The training matrix did not include this staff member, so we were not assured about the status of their training.

However, people told us they felt safe with the staff supporting them.

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 identified staff were not always provided with clear guidance when supporting people. At this assessment, we did not see sufficient improvements had been made to risk assessments and guidance for people who needed assistance to move safely. This included a lack of clear guidance in the safe use of equipment such as hoists and slings to support people safely. In addition, support plans and risk assessments for other known risks such as smoking and fire risks had not been developed to ensure people were safe. Risk assessments lacked clear guidance for staff to follow about how the risk should be managed. This included a lack of clarity on how to manage risks relating to people’s specific health conditions. For all the support plans we reviewed, some known risks had not been assessed at all, so there was no guidance for staff about how the risk should be managed, which had the potential to put people at increased risk of harm. There was a lack of information on how people should be supported in times of distress, which increased the risk to both the person and staff.

Whilst shadowing records were not detailed, staff members supporting people with complex needs told us they had the opportunity to shadow experienced staff members. This shadowing was designed to help them get to know the person’s care needs prior to working unsupervised.

Despite our findings there was no evidence people had been harmed. Staff knew people’s needs and told us they understood how to manage people’s care in a safe way. Overall records we looked at demonstrated people were supported by consistent staff.

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

The provider failed to carry out comprehensive environmental risk assessments of service users’ homes and provide associated guidance for staff to follow. One person’s support plan stated they had a history of putting cigarettes out on inappropriate and combustible objects. There were no risk assessments in place to mitigate such risks and reduce the potential for harm to both the person and staff. There was no evacuation plan in place in the event this resulted in a fire. Although support plans included an environmental assessment designed to check the safety of the service user’s home environment, these were not detailed or robust in identifying and managing the risks. The provider failed to identify and take steps to control potential risks within the environment care was delivered.

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, the provider's recruitment systems were inadequate and safe recruitment practices were not always followed. People were at risk of harm from receiving care and support from unsuitable staff. We continued to find similar issues with staff recruitment at this assessment as to those we found at the previous assessment.

Suitable references had not been obtained for some staff members. For example, references had not always been obtained from prospective staff's most recent employer or had been provided by people who had not been named as a referee on the staff member’s application form. This meant the provider had failed to ensure they had obtained all the information required ensuring the suitability of all staff employed. This placed people at risk as the provider did not know if staff were suitable to support vulnerable people. Where this had occurred, the provider failed to carry out a risk assessment to mitigate the potential risks this may pose.

Not all of the staff files which we looked at demonstrated a Disclosure and Barring Service (DBS) check had been completed prior to staff commencing employment. Two staff members’ records demonstrated they had gone into people’s homes to carry out shadowing duties without a DBS in place. The provider had failed to carry out any risk assessments in relation to this practice. In addition, they failed to ensure all staff working with children had the appropriate level of DBS checks carried out prior to them supporting children. The DBS provides information about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider had failed to evidence they had explored any gaps in employment records.

The provider continued to fail to have robust oversight of scheduled calls. Whilst many people were happy with their calls, we continued to hear from some people they did not receive their care calls on time and some told us they experienced short calls. We looked at a range of call records which confirmed for some people calls were often late and there were a high proportion of calls lasting less than half the expected time. One person told us, “Staff come late, I dread the weekend, it is worse. I appreciate there can be an emergency. It is not good.” This placed service users at risk of having their assessed needs not being met. However, some service users told the staff were never late and staff stayed the whole time.

We saw at least 2 people had experienced missed calls in the last 2 months; however, call records indicated this could be a much higher number. Some people told us and records confirmed a single staff member sometimes attended calls for people who required 2 staff to support them safely. One person told us, “If 1 [carer] is on annual leave the other works on her own.” This meant people were exposed to the risk of harm as the provider had not identified this was occurring.

We also identified staff were logging into 2 calls at the same time. The provider failed to identify this was occurring. This meant we could not be assured all people were receiving their calls as scheduled. Staff rotas demonstrated at times there was no travel time between calls factored in, or more than 1 care call was scheduled at the same time, contributing to late or shortened calls.

Although the training matrix indicated staff had received training there were no robust competency assessments in place to demonstrate staff learning following the completion of training. This meant the provider could not be assured staff had learnt and had the knowledge and skills to carry out such support. We found where specialised equipment was in place staff had not always been appropriately trained in the use of this.

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.

The provider failed to ensure where people used specialised equipment there were robust risk assessments and guidance in place for staff to follow. This included the cleaning of breathing equipment and the emptying and changing of catheter bags. This placed people at risk of cross contamination and the increased risk of infections.

We saw records where the provider had carried out spot checks to monitor staff were following safe practices and were adhering to the correct use and safe disposal of personal protective equipment (PPE). This included the use of gloves, aprons and masks. This had been improved following the last assessment. One person told us staff attended calls without wearing uniforms, but others told us staff wore uniforms.

Staff told us they had access to the PPE they needed to prevent and control the spread of infection and had received training. Most people and relatives we spoke with confirmed staff wore appropriate personal protective equipment (PPE).

The provider had an up-to-date infection prevention and control (IPC) policy in place, but they had not robustly implemented this guidance in the day-to-day support plans for people.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

At the last assessment we found people were not supported to receive their medicines in a safe way. We found there continued to be significant shortfalls in the safety of medicines management at this assessment.

Care plans and risk assessments continued to contain unclear or conflicting information or no information, to guide staff on the level of medication support people needed. For example, for 1 person whose support plans stated they did not require support with using breathing equipment and associated medicines, we found staff were recording as supporting with this. There was no guidance for staff to refer to for these procedures. This was unsafe and placed people at risk of not receiving their medicines, as prescribed. A relative of a person whose support plan stated staff did not administer medicines told us, “Sometimes they [staff] give medication. I draw up the medication into syringes. I have no issues they are great.” We found and the provider confirmed there was no medication administration chart (MAR) in place for these medicines. This meant staff did not have records to refer to, to ensure they were giving the correct medicines, at the correct time.

We saw and the provider told us there were people using the service who required medicines to be given at a specific time to control symptoms of health conditions, we found where calls had been missed these had the potential to impact on people’s health conditions and pain management.

We were told by 1 relative a person had their medicines crushed and given covertly. Covert administration is when medicines are administered in a disguised format. This means the person does not know they are taking a medicine. We found the correct guidance had not been followed prior to administering medicines covertly. The provider had not completed a risk assessment or support plan to guide staff on how to manage this risk safely. They had not sought health professional advice, such as from the prescribing pharmacist to ensure it was safe crush this person’s medicines before administering these covertly. This placed people at increased risk of harm.

There continued to be a lack of information for staff members to follow for the administration of 'as required' (PRN) medicines, to ensure a consistent approach. Since the last assessment, some guidance had been implemented for certain medicines; however, guidance on other PRN medicines was still either not in place or not clear as to when or why to use such medicines. Without clear protocols in place, this could lead to staff not knowing when to give these medicines, leading to the potential for too much or too little medication to be given.

We continued to find for people who were prescribed creams to treat skin conditions, these medicines were not consistently included on the person’s MAR or body maps. This meant people were at risk of their skin condition deteriorating and staff did not have the information they needed to provide safe application of prescribed creams. They did not have clear instructions on when, where, or how the creams should be applied. This was of particular concern for people who had skin conditions or were at risk of developing pressure sores as their prescribed creams needed to be applied to prevent further deterioration of their skin.

Many people and their relatives told us they were happy with the support they received with their medication, and they felt staff were trained to do this safely.