Dudley MBC Home Care Services

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 is 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 did not always investigate safety events to identify lessons learnt. Lessons were not always learnt to continually identify and embed good practice.

The oversight and management of safety events was not always effective. Where accidents and incidents had been documented, the provider did not always analyse these for understanding and learning. For example, records failed to demonstrate the provider analysed the causes and circumstances of how safety events might have occurred, and the actions taken for understanding and learning. This meant people were at risk of safety events not being appropriately managed.

A limited learning culture regarding safety events was also evident by the provider’s failure to review accidents and incidents within staff meetings. This meant staff did not have the opportunity to share learning to improve the safety of the service.

The provider did not always ensure safe systems of care. They did not always manage or monitor people’s safety.

Effective systems were not in place to ensure safety events were adequately analysed for understanding and learning, and that care plans always contained relevant information about people’s needs. For example, where people experienced incidents which impacted their health and safety as a result of their health conditions, incident records failed to refer to these health conditions and what may have caused the incident; at what stage of the incident staff provided support and whether there had been any learning from the event. Where people had health conditions which their care records stated caused them pain, their care plans and risk assessments did not refer to these conditions and how they impacted them. This meant people were at risk of their needs not always being clearly documented, used for learning and understood by staff.

However, the provider used effective systems in relation to obtaining the views of people, relatives and staff, staff recruitment and the oversight of staff practice.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The provider failed to manage safety events that had occurred and had affected people. Where accident and incident records showed people had been exposed to the risk of harm, these incidents had not always been reviewed and analysed by leaders. This increased the risk of incidents recurring, placing people at risk of harm.

Where the provider had identified people were at potential risk due to their needs, they had not always worked with healthcare professionals to mitigate these risks. For example, where people were identified as falls risks, referrals had not always been made to healthcare professionals, despite risk assessments stating there was a need to do so. This meant known risks were not always effectively managed, increasing the risk that people would not be kept safe.

People informed us they felt safe at the service. One relative told us, "Yes I do believe that he is safe. I see everything that they do.”

There was a safeguarding policy in place, records showed staff had completed safeguarding training and staff were able to tell us the action they would take if they had concerns. Leaders told us how safeguarding concerns would be reported to the local authority and Care Quality Commission (CQC), and care records demonstrated this had been done appropriately.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA). Where people had been judged as lacking mental capacity to be able to consent to their care arrangements, decision-specific mental capacity assessments and best interests decisions regarding key aspects of people’s care had been carried out to demonstrate decisions taken on people’s behalf were being taken in their best interests.

The provider did not always work well with people to ensure their needs and risks were clearly understood.

People’s care plans and risk assessments did not always provide information which accurately reflected people’s needs and risks. For example, care records did not always provide information which adequately detailed people’s physical health and safety needs. Where people had needs associated with health conditions, guidance was not always available to staff, meaning staff unfamiliar with people’s needs might not have been able to support them safely. This exposed people to the risk of receiving unsafe care and support as staff did not have clear guidance to follow.

However, there were some examples of care plans and risk assessments containing clear information, and staff demonstrated a good awareness of people’s needs and involved people in understanding and managing their own risks when we spoke with them.

The provider had systems in place to identify and manage risks within people's home environments.

Staff received health and safety training and demonstrated a good awareness of how to ensure people’s home environments and mobility equipment were maintained to mitigate potential associated risks.

The provider completed environmental risk assessments of people’s homes and undertook observational checks of people’s home environments as part of the quality assurance checks they completed of people’s care and staff.

The provider did not always make sure there were enough qualified and skilled staff.

Staff had not received training which was relevant to support some people’s needs. For example, records showed not all staff had received diabetes, epilepsy and palliative care training. Staff we spoke with also told us they had not received this training. This meant people were at risk of their needs not always being met by trained staff.

Safe recruitment processes were followed, and staff received inductions and regular supervisions with leaders. People and relatives were satisfied staff demonstrated the skills they needed to provide safe care.

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 service had an Infection Prevention and Control (IPC) policy which set out the provider’s IPC expectations. Staff received IPC training. Supplies of personal protective equipment (PPE) were observed in the office, which staff told us they had access to when they needed it.

People and relatives said staff used PPE when providing care. One relative told us, “They are very good with hygiene; they wear gloves.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Clear systems and processes were in place regarding the storage, administration and documentation of people’s medicines. Leaders told us how they used an electronic medicine system to monitor medicine practices, and they completed regular medicine checks and audits to ensure safe and appropriate medicines practices.

Staff received training in safe medicines management and staff we spoke with demonstrated good awareness of medicines processes and people’s individual medicine needs.

People and relatives told us they were happy with the medicines support people received from staff.