Archived: 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 was in continued breach of legal regulations in relation to people’s safe care and treatment, safeguarding people from abuse, and staffing.

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 guidance was required for staff on how to safely manage specific known risks leaving people at increased risk of harm. Although there was now a system in place for recording and analysing incidents, this was not robust and, in some incidents, not used. 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 staff statements gathered, detailed analysis of how such events had occurred, or robust actions implemented to reduce the risk of reoccurrence.

Staff supervisions were not carried out effectively to aid improvements in the service and ensure people’s safety. 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 response to these were not always robust, leading to repeated issues such as further late or missed calls.

People and relatives told us they could contact the service if they had any concerns, but that these concerns were not always addressed appropriately.

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

The provider’s standards of record-keeping about people’s needs and risks did not support their continuity of care. These records failed to demonstrate there was adequate information for robust continuity of care, including when people moved between different services. This included 1 person without a support plan that had been with the service for several months. This meant staff, or other healthcare professionals, attending may not understand the support the person required, and could result in their care needs not being met. The provider had not completed mental capacity assessments for any of the people using the service to determine whether they were able to make decisions for themselves or required decisions to be made in their best interests as it related to their safety and continuity of care when they moved between services.

Some people and relatives told us there was no care or support plan in the person’s home.

The provider failed to maintain consistent and comprehensive records of the support provided by staff to ensure records and actions were clearly documented and readily available to support continuity of care.

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.

We found the provider still did not recognise or respond to potential abuse in a consistent and appropriate manner to keep people safe. They had failed to report multiple safeguarding concerns to the local authority safeguarding team or notify the Care Quality Commission (CQC) of these concerns. For example, 1 person had reported 2 missed visits from staff in a single day leaving them without their personal care for a full 24-hour period. This meant the person had needed the assistance from their partner to go to the toilet and to provide other personal care. The person told us, “This is not how I want [name] to see me.” This was not recorded as a safeguarding concern, reported to the local authority safeguarding team, or notified to CQC by the provider. No investigation had taken place into these missed calls, and no preventative measures had been put in place to minimise the risk of this happening again.

Where safeguarding concerns had been recorded and reported appropriately internally, the provider’s investigation into these was not robust. There was no evidence of relevant staff members being spoken to and follow-up actions to keep people safe were not completed. The service failed to share the safeguarding concerns raised and outcomes of any associated investigations appropriately with relevant teams and healthcare professionals, including the local authority social work department.

Most 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 this assessment, we found sufficient improvements had not been made in relation to the assessment and management of known risks to people. There was a lack of clear information and guidance for staff on how to manage some known risks, including those associated with people’s health needs; on how to respond to foreseeable situations; and how to support people safely at all times. No individualised support plans or risk assessments had been developed for particular known risks, such as how to safely support people at times of distress and how to safely manage the risk of absconding. The provider’s failure to ensure staff had clear information and guidance on how to safely manage people’s individual risks put people at increased risk of harm.

A relative told us there was no communication from the provider when changes were made to the staff attending to their loved one, and there were regular occasions where a new staff member attended, although there had been no shadowing for the new staff, despite the complex nature of their loved one’s care needs. This meant there was an increased risk the new staff member was unaware of the person’s individual risks and needs, and how to safely support them in line with how they like their care to be delivered.

Despite our findings there was no evidence people had been harmed. Staff we spoke with knew people’s needs and told us they understood how to support people in a safe way. The care records showed that most people were supported by consistent staff.

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.

We found continuing problems with the provider failing to carry out comprehensive environmental risk assessments of care settings.

Multiple people told us they had not had an environmental risk assessment carried out since the provider started supporting them, over several years.

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.

Staff had the appropriate Disclosure and Barring Service (DBS) check completed prior to commencing employment. The DBS provides information about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

However, the provider continued to fail to maintain robust oversight of people’s scheduled care calls, to ensure they received reliable and punctual support. Whilst many people were happy with their calls, we continued to hear from some people they did not receive their care calls on time, were not made aware of changes to regular staff attending, and some people told us about receiving short calls. We looked at a range of call records which confirmed for some people calls were often late and there were a high volume of calls lasting less than half the expected time. One relative told us, “Staff come late and sometimes it’s someone [person] doesn’t know. I don’t get calls letting me know the staff are running late or if they’re changing the staff coming.” This placed people at risk of having their assessed needs not being met.

We saw people had experienced multiple missed calls in the previous 3 months that had not been identified by the provider but had been identified by the electronic call monitoring system (ECM), and electronic call records submitted by the provider indicated this number could be much higher.

We identified that staff were logging into 2 calls at the same time. The provider had failed to identify this was occurring and could not evidence if the staff had accurately logged in and out of calls from the person’s home. 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.

Face to face training was delivered by 2 of the management team, and online training was completed by an online training provider. The most recent face to face training was completed within 8 weeks prior to the assessment and attended by all care staff. The training was, in part, delivered by someone with expired training documentation. The certificates generated in completion of the face-to-face training, had another training company’s logo, and a recognised accreditation logo, added onto the certificates without the knowledge or permission of the company. Staff confirmed the training had taken place, but most were unable to say what the training was. This meant the training delivered was not sufficient for staff to retain the information given to them.

Although the training matrix indicated staff had received training there were no robust competency assessments in place to assess and 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.

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.

We saw limited evidence of 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.

One relative told us, “They don’t always change their gloves in between tasks. I’ve told the office about it, but it makes no difference.”

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.

We found continuing problems with people not being supported properly with medication. One person’s care plan instructed for medication to be given daily, and the staff notes confirmed the medication was being administered but there was no associated medication administration record (MAR) in place for the staff to complete. This meant the provider was unable to evidence what medication had been given and at what time, increasing the potential of medicines not being given as prescribed. Another person was being given medication by staff, but the task was not included in their care plan. Office staff confirmed they knew medication was being administered, when there was no MAR in place.

The provider had not completed competency checks on staff members for administering medication. This increased the risk of people not being given medication safely or in line with their prescriber’s directions.

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. Body maps were not in use to show where creams were to be applied, or for the staff to complete to evidence where creams had been applied. 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.