Dignity Direct Homecare Limited

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• 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

We identified four breaches of regulations. Risks to people's safety were not always assessed. Risk assessments did not have clear guidance for staff. Robust systems were not in place to ensure the effective recruitment and deployment of staff in accordance with people’s needs. The provider was not working within the principles of the MCA. People received their prescribed medicines; however, fire risk assessments did not accurately identify the risk of emollient creams for some people.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us they felt safe when receiving care from staff. A person told us “He (staff member) knows when I have had a bad night and checks me over and takes things slower until I wake up.” A relative told us, “My [loved one] has been receiving care for a long time now. I think my [loved one] is safe with them”. Another relative said, “The staff are very hot on checking for pressure sores and keeping fluid levels up, so I feel my loved one is safe in their care.” However, we received mixed feedback from people and relatives when asked whether staff sought permission from them when supporting them with their care. A person said, “I wouldn’t say they (staff) ask for permission before doing anything for me, but they are always respectful. There has been the odd one who was a bit rough, but they don’t stay long.” Another relative told us, I am occasionally there when the staff member comes and to be honest, I don’t remember her asking permission to do things, although she is always very polite and checks that nan is ok.”

When speaking to staff, they told us they would contact the office staff for any questions or concerns they had but were not able to tell us how they would deal with an incident other than calling the office. Staff were only aware of some forms of abuse and did not know what to do in the event of a safeguarding incident. Staff told us they would report concerns to the office but were unaware of other relevant agencies safeguarding concerns could be reported to. For example, a member of staff told us, “Tell the office”. Another member of staff said, “I would always speak to the office.” Although, staff received safeguarding training, their competency was not assessed to ensure they were fully aware of all forms of abuse and knew what to do in the event of a safeguarding incident in the best interests of people. When people were lacking mental capacity for care decisions, the branch manager was not aware that they had to carry out mental capacity or best interest decision making for any aspects of care and support. For one person, the branch manager identified a family member as an attorney but had no paperwork to validate this and did not know how to seek the Office of the Public Guardian (OPG) information about lasting powers of attorney (LPA). The relative had been asked for LPA health and welfare papers but had not provided them so assumptions had been made that the relative was able to make decisions on behalf of their loved one. Staff were not knowledgeable about whether people they cared for had been assessed to lack mental capacity, they knew when people had dementia, mental health needs and communication needs but not mental capacity. This meant that people were not supported to ensure they were involved with decisions about their care and decisions were made in their best interests.

Safeguarding records demonstrated that some safeguarding incidents were not clearly followed up to mitigate further risks. For example, one person who had previously developed a grade 3 pressure ulcer did not have a robust risk assessment in place to identity and reduce risks of further pressure damage. There was no robust care plan for skin health providing staff with a clear description of the person’s skin health needs and how to provide the specific care needed. Another person had a history of falls and required an Occupational Therapist assessment; however, the provider had not taken steps to follow this up. The provider had failed to work within the principles of the MCA to ensure consent to care and treatment was practiced in line with law and guidance. Mental capacity assessments had not been completed in line with legal requirements. When people had been assessed as lacking capacity or had fluctuating capacity to make decisions about their care, MCA's and best interest decisions were not completed. For example, one person had a learning disability and significant communication needs. Their needs could only be communicated via their body language; changes in behaviours and signing or pointing to objects of reference. However, there was no mental capacity assessment, no best interest decision making process undertaken and no court of protection measures in place for them. For another person, the provider had not carried out any mental capacity assessments to establish consent to care and support decisions, despite a care plan produced by the local authority which noted that the individual had advanced dementia and lacked mental capacity to contribute to their care review. This meant the service had not taken the appropriate actions to ensure decisions were made in people’s best interests. However, there were procedures for safeguarding adults and working with healthcare professionals to address safeguarding concerns raised.

People and their relatives were not involved in the development of their risk management plans. One person said, “There was one new staff member who really wasn’t cut out for the job and leaned their bodyweight right onto my (arthritic) body to reach across me (I shouted out in pain). They just left the room.” One relative told us, “I did complain to the office about the poor level of care provided by the cover staff member and suggested perhaps there should be more detail on the care plan, better handovers or better training to ensure that carers know how to get past an old person’s common wish not to be a bother to busy staff members.”

At this assessment we found the provider failed to assess the risks to the health and safety of people using the service and provide guidance for staff to reduce possible risks. Therefore, people were at risk of potential harm.

People’s care records did not have risk management plans which demonstrated that risks had been assessed in accordance with people’s needs and did not always include information about how to minimise associated risks and maintain people’s safety. This included no falls risk assessment, continence care risk assessment, use of equipment for moving and transferring people, pressure sore, behaviours of distress, diabetes, soft foods and liquids,, dementia, bed rails, and emollient creams. For example, the risk assessment for one person demonstrated they had risks associated with pressure sores/skin health, use of emollients, use of equipment for moving and transfer, use of bedsides, and diabetes. Another person, who used bed rails, had swallowing difficulties and there were also risks in relation to falls, mobility and transfers equipment, and use of emollient creams. However, for each of these people there was no further information for staff which detailed how the risks should be managed and monitored, including what measures were required to mitigate the risk and when concerns should be escalated to managers or relevant professionals.

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

People and their relatives raised concerns with staff timekeeping and missed care calls. 10 people out of the 24, we spoke with during the assessment reported issues with timekeeping. One person told us, “The morning call is very variable and can be anything between 10.30am-11.30am. I can work with 10.30am but I have then been in bed for 16 hours so my pad is soiled most days.” A relative said, “I think more effort needs to be made to make sure staff are staying the time and doing what is required.” Another relative said, “They (2 staff members) come 4 times a day and there has only ever been a couple of times when calls have merged because of delays on the previous call.” People and their relatives told us they were not aware if staff were adequately trained. A relative told us, “In terms of safety, there is only one staff member that is any good. I am not sure about the rest.” Another relative told us, “I feel like these women [staff] don’t have any idea of what’s going on and are not well trained on the equipment”. Another relative said, “They [staff] could improve the training, so they are more equal in skills.”

At this assessment we raised these concerns with the management team, they told us, they would take actions including reviewing call scheduling times for people, staff travel times and weekly unannounced visits to check double handed packages were being attended by both staff. Staff told us they felt supported and could approach the office staff at any time. Records showed and staff told us they received supervisions and training in relation to their roles.

Staff were not effectively deployed to meet people’s needs. The provider was using an electronic call monitoring system (ECM) to record staff attendance times. During the assessment we analysed the ECM data for 6114 calls for 49 people from 12 July 2024 to 12 August 2024 and identified failings with timekeeping and accuracy of recorded visit times. The management and oversight of the system was not effective. Of 6114, 1681 calls were more than 15 minutes late (27%) including 948 which were more than 45 minutes late (16%). 1954 calls were double handed (2 staff members were required to attend). Of these, 271 calls (14%) had less than 15 minutes overlap between care workers including 195 which had no overlap (10%). There were 164.5 pairs of calls where staff were logged in at two locations simultaneously. Widespread issues such as this can indicate a sign of ECM misuse. The provider did not follow safe recruitment practices and had not ensured appropriate pre-employment checks were completed satisfactorily before staff were employed. For example, 3 staff were employed without completing criminal record checks placing people using the service at risk of receiving unsafe care and support. Action was taken during the assessment process by the provider to address this concern. There were systems in place to provide staff with ongoing supervision and support. Staff completed training which, covered areas such as basic food hygiene, health and safety, moving and handling, infection prevention and control, promoting privacy and dignity, administration of medicine, and mental capacity act. Training records showed staff had received training on ‘awareness on mental health, dementia, and learning disability’ however, their competency were not assessed to ensure staff had sufficient knowledge and skills to support people with learning disabilities and autism.

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.

People and their relatives felt confident that medicines were administered in a safe and dignified manner. One person said, “They (staff members) give me my medication, but it’s all written down and there hasn’t been any problems.” One relative told us, “They [staff] administer my [loved one’s] medication and there has never been a problem.”

Staff had completed medicines training and their competency to administer medicines was assessed.

Medicines were managed safely. Staff completed medicine administration records (MAR) as required, to ensure people received their medicines as prescribed. Staff had completed medicines training. Their competency to administer medicines had also been assessed. The service had PRN (as required) medicine protocols in place for any medicines that people had been prescribed but did not need routinely. Senior staff carried out regular checks, to ensure people received their prescribed medicines correctly.