Bkind Care Ltd

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. The service was rated good for this key question at our last inspection. This key question has now been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

Safe systems were not in place to ensure staff had the skills and knowledge to provide safe care and support. Leaders had poor governance oversight which meant the care was not well-led. There were significant shortfalls in the oversight of the quality of care, monitoring of arrival times, responding to accidents and incidents and to then learn from accidents and incidents to make sure they did not happen again. Medicines were not managed safely.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt confident that any issues raised would be responded to. One relative told us, “One carer thought my [relative] had lost weight. They raised it straight away so we could sort it out. They are very aware of issues which is extremely helpful.”

Staff felt able to raise concerns and felt confident leaders would resolve this. One member of staff told us, “If I am stuck, I will ring [the Nominated Individual] to get advice on how to manage the situation.” Another member of staff told us, “If there is a concern, I would go into the office or I would ring [the Nominated Individual]. I would call them.”

Accidents and incidents were not reviewed and learned from to minimise the risk of it happening again. There were systems and procedures in place to record accidents and incidents but these were not reviewed effectively to make people safe. The appropriate action was not always taken which increased the risk of harm to people. The provider had some systems in place for monitoring and learning lessons when things went wrong, however these were not effectively used. We found analysis, audits or oversight of accidents and incidents where themes and trends were not always identified. For example, there was an incident where medical assistance was not sought by staff. Leaders did not review this incident to understand what had happened and what could be learned from this. The lack of learning meant people were at continued risk of harm in the future.

We received mixed feedback from people on their experience of care. One person told us, “I was in hospital earlier in the year and I asked for the same carers back. I’m ok with them.”

Staff said communication was good from leaders at the service and they had the information needed to provide safe care. One member of staff told us, “I just follow the care plan. I do what [managers] tell me to do. The care plans are really good and give me the information I need.” Another member of staff told us, “I follow the care plan and do what the manager said I had to do.”

Partners did not give feedback about safe systems, pathways and transitions at the service.

People’s care plans were not always kept up to date and they contained out of date information. For example, when someone had fallen, their care plan or documentation was not updated to tell staff there had been a change. The lack of documentation being updated meant staff would have not known they needed to provide additional monitoring place to minimise the risk of the same incident happening again.

People and their relatives told us they felt safe with the care they received. One person told us, “I feel very safe with the carers.” A relative told us, “Yes, I think [relative] is quite safe.”

Staff felt they had the skills and knowledge to raise concerns about abuse or neglect. All staff we spoke with demonstrated an understanding of safeguarding adults. One member of staff told us, “If I had a concern, I would tell the manager.” Another member of staff told us, “I would report [a safeguarding concern] to the office straight away.” Leaders knew what safeguarding was and they reported safeguarding concerns to the Local Authority. The nominated individual told us, “I call the Council if there is a safeguarding.”

Safeguarding policies and procedures were in place and available for staff and leaders but these were not always followed when a safeguarding incident occurred.

People told us they were not involved in the management of their risks. One person told us they had an initial meeting with the registered manager but they told us they had not seen a copy of their care plan. Another person told us, “I have never seen a care plan.” A relative told us, “[My relative] have had the agency for about 2 years and when I came out of hospital earlier in the year, we had a sort of review but we have not seen a care plan.”

Staff felt they had enough information to manage people’s risks. One member of staff said, “I follow the care plan.” Another member of staff said, “I use the [digital care plan] app, it is all ok and I am comfortable with using the app.”

Processes were not in place to manage the risks people were exposed to safely. We found no evidence risks to people had been assessed and documented. For example, one person had a catheter which was managed by district nurses. There was no care plan or risk assessment in place for this l and the care plan incorrectly identified this person used alternative continence products. While people had care plans, these were basic and often had a generic single line of information per section such as “use incontinence pads” within the continence care section of the care plan. Care plans did not include all relevant information. We found examples of vital information missing, such as an absence of the person’s wish whether they wanted to have cardiopulmonary resuscitation (CPR). The lack of this information could delay life saving treatment. We found care plans were not always accurate and contradicted themselves.

The failure to have adequate assessment of risk to people was a breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they received personal care and support within their own home. People and their relatives told us they had not seen environmental risk assessments or specific guidance for staff to ensure people’s safety within their home environment.

The Nominated Individual told us a senior member of staff visits a service user to complete a holistic assessment of their care needs. However, we found all risks were not assessed or responded to appropriately and there was a lack of detailed planning on how to manage identified risks.

Risk assessments had not been completed to guide staff on how to manage environmental risks, using equipment within a person’s home or how to respond to unexpected events. For example, one person’s hoist malfunctioned, and staff used an alternate hoist in the person’s home. There was no moving and handling care plan or risk assessment to guide staff how to use the hoist, and what to do in the event of a hoist malfunctioned. While the person was safe, the provider did not anticipate, assess or plan for this scenario to ensure staff had a clear understanding of how to respond.

People we spoke with felt staff did not have the right training to do the job. One relative told us, “I think training varies a lot, some are very good but mostly they don’t understand dementia.” Another person told us, “I don’t think the staff are well trained. The regular ones are ok. I once had carers and none of them knew what to do.” Other people did not have a positive experience where they told us, “I haven’t seen a rota.” While another person told us, “I have lots of different carers.”

Staff told us they had the skills and training to care for people , including care for children or people with a learning disability or autism. Some staff said they had completed training on autism but could not remember any details of this. One member of staff told us, “[The training] was good enough. We did both face to face and online training. It gave me the skills to do the job.”

The provider did not always ensure that staff had a robust induction to give them the skills and knowledge to provide safe care. The service was registered to care for children and people with a learning disability and autistic people. Staff did not receive any training on these subjects, and they did not have the skills necessary to provide care for people with these needs. While staff were recruited safely, the provider did not follow its induction policy by holding regular meetings and random checks with new staff. The service therefore could not assure itself that staff had the right skills and knowledge following their initial training. Where there were specific concerns or allegations made about staff members, there was no enhanced monitoring or assessment of this risk to protect people from the risk of harm.

The failure to ensure there was safe and effective staffing was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People received support from staff who safely managed the risk of infection transmission. One person told us, “Staff are good. They wear gloves and aprons. They are very clean and tidy.” Another person told us, “One of the carers wears a mask but not the others. The others wear gloves and aprons.” All the people we spoke with had a positive experience with the management of infection with a third person telling us, “The first thing staff do when they come in is wash their hands.”

The Nominated Individual told us all staff complete infection prevention and control training and staff are all provided with personal protective equipment (PPE). Staff confirmed this when we spoke with them. Staff told us that they received training on infection prevention and control and they had access to PPE.

Processes were not always in place to manage infection prevention and control safely. While staff, leaders and people told us staff wore PPE, the provider did not have robust and consistent methods to make sure staff wore PPE and managed infection risk consistently.

People told us they received their medication safely. One person told us, “I do my own medication and the staff check. They put my cream on too. The staff contact my doctor and pharmacy to get my repeat prescriptions.” A relative told us, “I sort out the medication and the carers just prompt [relative] just to make sure they have taken it.”

Staff told us they had the skills to safely administer medication. One member of staff said, “Yes, I did the proper training. This was face to face.” Another member of staff, who was new to care, told us, “I have had the medication training, but I cannot remember if I have had any checks to make sure I was giving medication safely.”

Medication was not safely managed and administered. There was a widespread culture of staff not administering medication but recording medication had been left for the person to take later. Provider audits had failed to highlight and address the risks of poor practice. There was a lack of clear and robust documentation to guide staff how to apply emollient creams. One person did not have clear instructions on where to apply their emollient cream therefore different staff applied this to different parts of the persons body. People who needed medication “as and when required” did not have any plans in place guiding staff when these medications needed to be given and why. The service was also not responsive to a person’s changing care need. One person was increasingly struggling to order their own medication and on two occasions, ran out of medication as a result. While staff collected this on the persons behalf, there was no reassessment to understand if the person needed additional support in managing their medication.

The failure to have medication managed safely is a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008.