Alchita Care Limited of Bradford

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 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 how people’s medicines were managed safely at the service.

This service scored 34 (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. Although we found incidents were reported in detail, actions were not followed up, for example people’s care plans were not updated. There were no policies and procedures in place for managing safety events. There was no monitoring of themes and trends in accidents or incidents. This demonstrated a poor culture regarding learning and acting upon information.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There was evidence to show people’s needs had been assessed prior to using the service to ensure the service could meet those needs.Although the preadmission documentation was person centred and detailed, care plans and daily records did not always reflect the preadmission documentation or reflected what support people needed. For example, we found care records for someone at risk of choking to be inconsistent and lacking guidance for staff. They did not lead staff to provide safe care to manage this risk and did not provide assurance people were referred for support when needed.

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 always share concerns quickly and appropriately. While people and their relatives we spoke with told us they were happy with their care, we were not assured care met the expected standards. Systems to ensure that people were safeguarded from abuse and improper treatment were either not in place or not followed. For example, there was no safeguarding policies or audits. Although we found no unreported safeguarding incidents, the recording of safeguarding did not include vital or important information. The provider did not have a system to record and learn from safeguarding incidents. The provider missed opportunities to make improvements and to learn from any patterns and trends to reduce the risk of future harm to people using the service.

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. The provider did not take appropriate action to mitigate risks. Risk assessments did not contain up-to-date information and did not cover all potential risks. For example, we found a service user at risk of choking did not have a sufficient risk assessment in place. Information was not up to date and there was no information available to staff on how to reduce the risk of choking. This meant people could be at risk of potential harm, and staff were not provided with the appropriate guidance to support them safely. Staff were unable to demonstrate how they supported people to independently manage their individual risks.

There was no evidence people were involved in planning their care or managing risks. Care plans were out of date or not in place. This meant we could not be assured care plans appropriately met people’s needs.

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. The registered manager completed pre-admission visits and completed home risk assessments. However, home risk assessments were not always reviewed, and we could not be assured information was up to date. There was no lone working policy in place to support staff safety.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not make sure staff received effective support, supervision and development. Staff were not always trained to care for people with specific conditions. They did not always work together well to provide safe care that met people’s individual needs.

Records related to recruitment did not always demonstrate a robust process. There were gaps in employment history, with no evidence to show that these had been investigated further.

The service is registered to care for people with a learning disability and autistic people. However, not all staff had completed training in these areas.

Staff did not receive regular spot checks, competency checks, appraisals or supervisions. Staff reported the provider employed enough care staff to meet people’s needs. One staff member told us, “There are no shortages of staff and enough time to travel between calls.” However, feedback from people and their relatives conflicted with this, including comments such as, “[Staff] don’t always stay the full time,” and “[Staff member] used to call and put [person] to bed at 7pm instead of 8pm.”

The rotas did not consistently show staff were allocated to visits nor did they evidence that care was being carried out at the correct times or for the correct durations. There was no evidence of audit processes to monitor actual call times or missed calls.

The provider did not assess and managed the risk of infection effectively. However, they detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Although staff demonstrated a good knowledge of infection prevention and control (IPC) and were up to date with IPC training, IPC spot checks were not completed regularly, and the service did not have any IPC policies and audits in place.

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 their care. There were issues within medication administration records (MARs). For example, some MARs were missing allergy information, and there were gaps where staff had not signed to confirm medicine administration. Medicine audits did not identify the concerns we found during assessment and contained incorrect information about people. Staff did not have access to a medicines policy to support safe administration. Additionally, medicines did not always include clear instructions to guide staff.