Kaplan Care

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

We found that the service continues to Require Improvement in relation to the Safe domain. We identified one breach of the legal regulations. People’s risks assessments were not detailed enough to give staff information about how to support people safely, particularly around people’s health needs. Safeguarding procedures were not followed. Lessons were not always learned when things went wrong and from incidents and accidents. Staff were not supported to be effective in their roles. There were enough staff deployed to meet people’s needs and there was good care continuity.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives knew who to report their concerns to. They told us they would report any concerns or incidents to the provider. However, some relatives told us that the provider was not always available and accessible when they needed to speak to them in the past. They gave examples of when they had tried to contact them in the past but were unable to. They commented that this had improved in recent months as the provider have become more involved in the service and was available to respond to concerns.

The provider told us staff were required to notify them of any incidents or concerns. Staff knew how to report incidents or their concerns about people’s care. Staff told us they used the care planner to record incidents and concerns about people’s day to day care. They said they would also inform the provider about incidents or when things went wrong but they commented that the provider was not always available and accessible.

There were processes in place for reporting incidents, but staff did not always follow this. They were reporting incidents externally and not informing the provider. There had been two incidents that had been reported to the local authority. The local authority notified the provider about these incidents. The provider told us about the actions they took to address these concerns. A member of staff had to complete a refresher training in moving and handling following a moving and handling incident. They also shadowed an experienced staff member to embed that learning around how to support people appropriately. The other incident was about a missed visit. The provider told us they completed the visit when they realised it, and they apologized to the person. They reminded staff to check their rotas and update the care planner application to mitigate the risk of such an incident re-occurring. We found however, that the provider had not maintained a record of these incidents and the actions taken. There were no processes to enable staff to learn from these incidents. There was no evidence to show how learning from incidents was discussed and shared with staff to improve their learning during team meetings.

People told us that an assessment of their needs was carried out before they joined the service. People and their relatives told us staff contacted them and shared information and concerns with them.

One staff member told us they would contact people’s GP if they were unwell. They said they would share information appropriately with other agencies. Staff gave us examples of how they had worked with people’s relatives to ensure they got the treatment they needed. Staff told us they also shared relevant information with each another.

We contacted health and social care professionals involved in people’s care for feedback but did not receive any feedback.

There were processes in place to ensure people had a smooth transition when they moved from one service to another. People’s care records also included information about them such as their background, likes, dislikes, allergies and medical history. People’s care was planned based on their identified needs. Staff liaised and followed recommendations made by professionals involved in people’s care. One person was cared for in bed following a recommendation made by the occupational therapist. Records showed that people were supported safely.

People told us they felt safe with staff. One person said, “They [Staff] are nice to me.” One relative told us the care staff were lovely. People and their relatives knew how to raise their concerns appropriately. They told us they would contact the provider or the local authority.

Staff had undertaken safeguarding training. They were able to identify the various types of abuse and signs to recognise them. Staff knew the systems in place to raise safeguarding concerns in line with the provider’s procedure which required them to report to the registered manager or the provider. However, staff expressed concern that the provider was not always accessible and available and there was no arrangement in place to support staff when the provider was not available. Some staff members commented that they did not completely trust the provider to address concerns because they did not always communicate openly with them. The provider lacked understanding of their role and responsibility to safeguard people from abuse. The provider knew their role to investigate safeguarding concerns and involve other agencies such as the police if needed. We found they did not fully understand that they need to notify CQC of safeguarding concerns raised about the service. We found that the provider had failed to notify CQC about a safeguarding matter that had been raised about the service, they told us they didn’t know they should send a notification because CQC were already aware of the incident.

There was a safeguarding procedure in place which stipulated how to address and report safeguarding concerns to the registered manager. The service’s safeguarding policy stated, “a written record of any concerns will be kept on file.” We found that there were no records of safeguarding concerns raised about the service. There had been three safeguarding concerns which had been reported to CQC by the local authority and staff. The provider had been made aware of them by the local authority. The provider told us that staff had not reported these concerns directly to them, so they did not consider keeping a record of them. The provider had failed to follow their process and policy. The local commissioners told us that the provider had met with them to discuss a safeguarding that was raised but had not sent them the supporting evidence they requested for promptly.

People and their relatives told us staff had improved in supporting people to manage risks they faced. One relative mentioned that when some new staff started, they were experienced in supporting people with catheters to manage this risk, but they had now been trained and they have improved. People and their relatives commented that they worked with staff to mitigate risks to people. For example, one relative commented that they shared the recommendation of an occupational therapy with staff on how to manage their loved one’s safely in bed. Staff followed the recommendation and supported the person safely.

Staff knew the risks people faced and how to mitigate the risks. Staff told us they shared information with each other about people’s care, so they knew what to do and how to care for people safely. They told us they worked closely with people and their relatives, and they shared any concerns with them. One staff member said, “We follow the care plans to know how to care for people. We also speak to the family about anything, and they advise us what to do.” Staff told us they shared information with each other if they were concerned about anything or wanted the next staff to be aware of any risks. The provider told us that they collaborated with people, their relatives, and staff to manage risks better. One relative had informed the provider of a planned review. They agreed they would share the outcome with them and update the care plan if needed.

Risks to people were not always identified and managed to ensure people were kept safe. Risk assessments and management plans did not always include information about how to minimise associated risks and maintain people’s safety in accordance with people’s specific needs. One person had bed rails on their bed which staff put up for them when they were in bed to reduce the risk of them falling. The person’s relative told us they had instructed staff to use the bed rails which staff had been using. The person’s care plan stated that staff should put up the bedrails when the person is in bed. However, we found that there was no risk assessment in place on the use of bedrails. There had not been any measures put in place to mitigate any risks. We also found that there was no risk assessment completed out to identify potential risks to a person who staff supported with their catheter. There was no information provided to help staff identify when there might be a problem such as blocked tube, unusual urine colour or odour, and what actions staff should take if they had concerns. The care plan only stated staff to check and empty catheter bag. This placed the person at potential risk of harm.

People were supported in a safe environment adapted to meet their needs. People told us staff kept their home environment free from hazards. People had the equipment they needed to promote their safety at home.

Staff supported people to maintain their home environment. They told us they checked people’s home environment and supported them to keep their environment free from hazards. Staff reported any concerns about people’s home environment appropriately to people’s relatives and to the provider so the issues could be sorted out.

Training records showed staff had received health and safety training, including moving and handling and fire safety. People’s home environment was assessed and care plans reminded staff to monitor and check people’s home environment regularly.

People and their relatives told us staff were not always effective in carrying out their roles. They said staff lacked the training and experience required for the job. One relative expressed that some staff members could not deliver basic tasks such as making their bed properly and making a meal. Another relative mentioned that they had some recent concerns with the new staff because they were not experienced in catheter care. The relatives confirmed they had now been trained and had improved. People told us that staff attended their care visits as planned. They told us that they were occasionally late, but they always informed them if they were running late.

Staff feedback was mixed. Some staff told us they felt supported in their role while other staff members told us they did not feel supported. The new staff members told us they had an induction when they started. They told us they shadowed an experienced staff member, so they learnt how to support people to deliver appropriate care. One staff member said, “We support each other. The care coordinator gives me supervision. They support me with anything. If I have a problem I go to them. I had a supervision with them in the summer.” Another staff member told us they have not had any supervision since the new provider took over. They told us they did not feel supported in their role because the provider was never available when they needed support. This had impacted on their ability to carry out their role effectively.

There were sufficient staff to support the number of people who received care at the time we visited. There were six staff members available to support four people. Records showed people received their call visits as planned. There was an electronic system used to schedule care visits and staff knew their allocated visits in advance. Staff were recruited safely. We saw records showed staff had the Disclosure and Barring Service (DBS) and their references checked when they started. Staff had received relevant training for their roles and responsibilities. We saw training records which showed staff had undertaken training in safeguarding, moving and handling, Mental Capacity Act, infection control and other specialist training such as catheter care and end of life care. Staff did not always receive the support they needed in their roles. There was no record of regular supervision for staff. We saw a record of supervision for one staff member and two spot checks done in October 2024. There was no other record of supervision and induction completed for staff. This confirmed what staff had told us about not feeling supported in their roles.

People told us staff always used personal protective equipment (PPE) appropriately and followed infection control procedures. They told us staff maintained good hygiene practice by washing their hands and wearing PPE as necessary.

Staff told us they followed infection control procedures. They used PPE provided by the provider. They said they always wore the appropriate PPE when carrying out personal care tasks or when dealing with bodily fluids and promoted good hygiene by washing their hands effectively and disposing waste appropriately.

The provider had an infection control policy and procedure available and provided PPE to all staff. Staff had received training in infection control and told us they used PPE when carrying out tasks such as personal care and food preparation.

People told us staff administered their medicines to them as planned. People and their relatives agreed to staff supporting them with their medicines as part of their care and support needs.

Staff told us they followed guidance in place when administering people’s medicines. They confirmed that they had been appropriately trained and felt confident to administer medicines safely to people. Some people were prescribed medicines to be taken only when required known as (PRN) medicines. Staff understood PRN protocols and told us they recorded medicines given as required.

There was a medicine management procedure in place. Staff had received training in medicine administration and management. There was a record of people’s medicines which showed which medicines people took and how they were administered. The provider audited medicines administered to identify any errors.