People put ‘at risk’ with inconsistent care visits
DAMNING REPORT RATES PROVIDER ‘INADEQUATE’ AND IT IS PLACED IN SPECIAL MEASURES
DOZENS of care visits to vulnerable people waiting for personal care in their own homes were missed by a Swadlincote agency, which has been labelled “inadequate” and placed in special measures.
At other times, only one Sycamore House carer attended a resident instead of two, which led to a person falling during a care visit. Visits were missed on at least 31 occasions
The agency, based in Ryder Close, was contracted to provide care in the homes of 25 people at the time of an inspection by inspectors from the Care Quality Commission (CQC).
This included people with physical disabilities, dementia and other long-term health conditions. The service was previously inspected and a report published in April said it “required improvement”.
But a newly released inspection report from a visit in late July and early August said the service “had deteriorated to ‘inadequate’” and people were “at risk of avoidable harm”.
The report says people did not always receive visits for the assessed duration, which placed them at risk of having “insufficient and unsafe care”.
One person’s daily call logs showed five calls out of 12 were completed in five minutes or under and the longest call was 13 minutes.
Another concern in the report was that guidance was not consistently provided to staff about people’s health conditions and how this impacted on their care.
The report said: “For example, one person had a diagnosis of Parkinson’s disease and another person had diabetes, risks associated with these needs had not been assessed or planned for.
“One person had high blood pressure, their daily care records showed on occasions staff checked and recorded this. This care task was not included in their care plan or risk assessment so staff did not have guidance on how to do this safely. A lack of guidance and clear instruction for staff put people at risk of unsafe care.”
The report says that a “high number of staff had left the service” meaning there were insufficient staff available to meet people’s care needs. The inspector was told that 82 people had left between the two most recent inspections. “People were put at increased risk because they experienced late or missed calls. One person told us they were supposed to receive four calls a day but how the last call was frequently missed. “Another person said, “Probably a couple of times a week they (staff) are late. Daily logs confirmed frequent late calls. This put people at increased risk.”
A high number of complaints were made to the company, which is run by RLS Care Services Ltd, including from a local authority and by the time of this inspection, it had “suspended its contract for new referrals and had moved a high number of people to different care agencies due to concerns about risks and safety”.
Summing up the situation the report said: “Continued shortfalls were identified in the systems and processes that assessed, monitored, and mitigated risks and quality. There was a lack of effective oversight and leadership of the service.
“Incident and risk management, including analysis and learning lessons when thing went wrong were not fully effective. People were not sufficiently protected from the risk of abuse.
“The provider had failed to notify the Care Quality Commission of all reportable incidents they are legally required to do.
“Best practice guidance in the management of medicines was not followed. New staff did not receive probationary meetings to monitor their performance. Staff did not feel supported or valued and raised concerns about the quality of training, communication and organisation.
“Infection prevention and control best practice guidance was followed.”
The CQC says it will keep the service under review. It said: “If we do not propose to cancel the provider’s registration, we will re-inspect the service.
“If the provider has not made enough improvement and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures.
“This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.”
Despite the company being approached in person, no-one wished to comment.
A lack of guidance and clear instruction for staff put people at risk of unsafe care.
Care Quality Commission report