Archived: Exclusive 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

The principles of RSRCRC were not met, people were not always kept safe from avoidable harm and the service did not work well with other agencies to do so. Staff did not always consider a least restrictive option before limiting people’s freedom. Staff did not always have specific training to support people’s needs. Medicines were not always managed safely. People did not consistently receive safe care because staff and the provider did not learn from safety incidents. During our assessment of this key question, we found concerns around the management of incidents and accidents and the risk associated with people’s care. We found 3 breaches of the legal regulations in relation to safeguarding, safe care and treatment, and staffing. People were not protected from the risk of abuse and had been harmed. Risks to people were not adequately assessed and staff were not adequately trained or skilled to support people.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us they ‘regretted any shortcomings’ and were ‘committed to ensuring the safety and wellbeing of the people they supported.’ The registered manager and provider told us they recognised the documentation and investigation of incidents was not robust. We asked staff if information about incidents was shared with them. Although staff told us learning was shared, they could not give any examples, including for example staff who were supporting someone who had recently sustained a burn.

Incident management and oversight was poor. Incidents were not always recorded and reported by staff. For example, one person was dropped from the hoist, and staff who were not trained picked the person up from the floor. Staff failed to report the incident to the registered manager. When the registered manager was made aware of the incident, a complete investigation was not carried out, and they could not demonstrate any leaning or improvements implemented. There was a lack of robust documentation and assessment of incidents and concerns shared about the service. The registered manager had two spreadsheets where incidents, complaints and safeguarding’s were logged, however this was not fully completed, and did not always detail actions taken to mitigate risks. In some cases it did not include further information about incidents, and had incorrect information documented.

While some people and relatives we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. A relative told us their loved one had a fall. A staff member had not sought any medical help for the person which had resulted in a serious injury. There was no learning from this incident and the provider had poor oversight of accidents.

Staff told us when assessments were completed for new packages of care, the registered manager would decide if they would take the package forward. Consultation with staff was not always completed by the registered manager to ensure there were sufficient staff, and staff had the relevant skills to support people. Some packages were implemented regardless of feedback from staff if they felt the person’s needs could not be met. People’s care journey was not monitored and managed in an effective way to keep people safe. Staff were not proactive to manage risks to people. Staff told us that due to the high volume of new packages starting, they were unable to fully assess and identify risks to people who were new to the service to ensure care plans and risk assessments were in place to inform staff of how best to support people safely.

While some people and relatives we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. A relative told us when the package of care started for their loved one communication was extremely poor and staff had been given incorrect information about their loved one’s needs. The relative said the transition into the service was not smooth or easy. Some people fed back they had received a positive experience in relation to the package of care commencing.

There were not always safe systems, pathways and transitions in place to ensure people received the support they required. The complaints log evidenced when people were unhappy with the care they received, some made the decision to end the care package. For example, following an incident in December 2023 of staff neglect, the family made the decision to end the care package. The providers documentation was not accurate with the reason the care package ended. People were not always supported with a smooth transition to another care agency or left without support. From January 2023 to the time of our assessment the providers records evidenced 59 care packages had been terminated without any detail or reason why the package ended.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The registered manager and provider accepted medicines management was poor. Not all staff were clear about the medicines people required. For example, 1 person had a PRN medicine Lorazepam. Staff said, “We give him meds, yes it’s as and when meds,” the staff member could not remember the name of the medicine. Another staff member fed back regarding the same persons medicine “Not sure about Lorazepam, I didn’t know this was prescribed.”

There were ineffective systems in place to ensure medicines were managed safely. Some people were prescribed ‘as and when’ medicines. There was no guidance in place to inform staff when this medicine should be administered, and how to check if it was effective. One person was prescribed a PRN medicine Lorazepam to be given when they became distressed. However, we identified they had been administered the medicine 3 times in February 2024 without a documented reason for administering. The person’s daily notes documented the person had been happy on these 3 occasions. On 1 of these occasions staff administering the medication had not had any competency checks to ensure they were capable of administering medicines safely. Some people were prescribed pain patches. These are patches applied to the skin that release a measured dose of pain relief through the skin. The position of pain relief patches was not recorded. This made it difficult to know if a replacement patch was positioned on a different site to help prevent skin irritation, or possible skin breakdown. The registered manager and provider did not complete any checks or audits to ensure medicines were administered as prescribed. The registered manager and provider failed to identify that ‘as and when’ guidance was not in place, or that pain patches were being administered and documented in line with the prescriber guidance.

While some people and relatives we spoke to expressed that they were generally happy with how their medicines were managed, our assessment found care did not meet the expected standards. A relative said their loved one’s medicines storage had been left open on at least 2 occasions and their medicine had been missed at least once. They reported this to the provider, but no robust action had been taken in response to their concerns. The provider said they would “Pull in the staff member.” But there was no other information about how the provider would ensure the person’s medicine would be managed safely or how they were assured staff were competent to deal with people’s medicines.