Kemfa Services 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

The key question of safe was rated as good at our last assessment. At this assessment the rating had deteriorated and the key question of safe is now rated requires improvement. During our assessment of this key question, we found various concerns including the management of risks to people’s health and wellbeing, safeguarding, medicines and staffing which resulted in a breach of safe care and treatment. You can find more details of our concerns in the evidence categories below.

This service scored 44 (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 failed to ensure their management and oversight of complaints, accidents and incidents was robust. The provider had limited oversight of concerns and incidents. Not all risks were identified and acted on appropriately to ensure people’s safety or look for ways of learning. Complaints from people were not fully investigated, and the provider had missed opportunities to identify safeguarding concerns from complaints. The provider could not demonstrate learning or improvements they had implemented and sustained as a result of learning.

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.

The registered manager told us they had identified the need to implement safeguarding procedures to give them oversight. The registered manager showed us recordings of safeguarding concerns however the documentation was poor. For example, the registered manager was unable to show a clear pathway between safeguarding concerns being reported, investigated and learnt from. Staff discussions held in relation to safeguarding concerns were not easily accessible to evidence robust documentation systems. The registered manager told us there was a planned change in management structure aimed at improving safeguarding systems.

Safeguarding systems were inadequate and ineffective. The registered manager failed to ensure all safeguarding concerns had been referred appropriately to the local authority for investigation and we could not be assured all concerns had been investigated or that measures had been introduced to reduce further risk. There was no process or system in place to analyse safeguarding concerns to identify themes and trends, learning and reduce the risk of reoccurrence. The provider had implemented an action plan and submitted statutory notifications in retrospect. The provider had identified improvements were needed to introduce robust safeguarding systems and plans to have a designated safeguarding lead.

We received mixed feedback from people. For example, one person said, “Staff don’t know me. They change every week. We try to be sociable. Frustration comes from one way communication.” People had told the provider they needed support at a specific time for particular reasons, the provider did not always ensure care workers attended at these agreed times. People also told us when they complained about care workers not being available at the agreed times the provider was not able to sustain improvements. People told us they were aware of the care plans and some people had a review in the days leading to our assessment. People told us they were happy with their care plans. One person said, “I require two carers for my personal care, they arrive separately but the first carer will wait for the second to arrive before starting.”

The provider did not have effective systems in place to ensure care records in relation to the care and treatment needs of each person were up to date and reflected their current needs. The provider had failed to identify some records such as detailed care plans and risk assessments were not in place, some lacked specific details such as epilepsy information, catheter care, and others lacked detail around manual handling and the use of equipment. This meant staff did not have the correct information they needed to provide safe and effective care.

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 received mixed feedback from people and relatives. Relatives did not always feel newer staff had been fully inducted. A relative said, “Sometimes they send new carers, and they don’t always shadow first.” And another relative said, “The regular carers seem well trained, and they know [relative] well, but I do sometimes feel the new ones are not trained well enough.” Another person said, “They (care workers) all seem well trained and know what to do.” People told us they felt staff were under pressure due to traveling between calls. One person said, “I don’t like to be rushed and quite recently they do seem to want to get off quicker, one of my regulars seems to rush me.” Other person said, “I am happy with them all (Care workers). They appear to be kind people and caring.” A relative said, “I do think they show respect just by the way they are and how they treat [family member]. I am sure if we asked them to do extra little things they would, but they do everything that they need to anyway.”

The provider had failed to identify that staff training was not fully effective. The provider lacked systems for robust oversight of the service. Some records required for the effective running of the service were not available to us on the day of the assessment or provided to us in a timely manner following our assessment. For example, documents related to the safe recruitment of staff, staff training and documentation relating to staff disciplinary action were not available to us when we requested them.

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 provider had failed to manage medicines and systems associated with medicine administration safely. For example, we identified a person who required staff to be trained in the safe administration of emergency epilepsy medicine. We identified staff working with the person did not have training in the safe administration of this medicine. We also identified poor administration of medicine records, this meant information was not clearly recorded to provide staff with clear instructions for administration. There were no protocols for ‘As and When’ (PRN) medicines in place to provide guidance for staff about how and when they would need to give medicines such as pain relief. We also identified where call times did not leave enough time between people’s medicines to help ensure they were given in accordance with the prescriber’s instructions. Since our assessment the provider has implemented an action plan to make improvements to the way medicine is managed.