KEPA Care Solutions 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 three breaches of the legal regulations in relation to safe care and treatment, staffing and safeguarding. We found that people were not always safe when being supported by staff. Care plans and risk assessments were not robust, and staff response to incidents was inconsistent. When people were distressed, staff used unapproved and unlawful physical intervention, and not all staff had received training in this area. Medicines management was poor and key information was not documented within people's care records, including for example if someone needed an emergency rescue medicine. When medication for distress had been administered it was not documented within medication administration records (MAR). The principles of RSRCRC were not met; people were not supported by staff who were sufficiently trained and understood how to support people with a learning disability or autistic people. Incident documentation and learning from incidents was poor. Safeguarding processes had not been followed by the registered manager; we identified incidents which should have been reported to the local authority safeguarding team and had not been.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the people we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. When incidents occurred between people the registered manager did not always take appropriate action to address and mitigate risks to people. Similar, serious incidents between people re-occurred for example, there were multiple occasions when one person spat at another, and multiple instances when one person targeted another person. Some people had been subjected to the use of restrictive practices, such as physical intervention. When this occurred, managers did not review the use of restrictions to look for ways to reduce them, and this impacted on people's human rights.

Leaders did not prioritise people’s safety. There was a lack of openness and transparency which put people at risk of harm. Staff told us they documented all incidents and accidents on an electronic system. However, we identified one incident where a record had been removed from the system. Staff explained a recent incident to us and told us that it was documented on the electronic system. When we reviewed the electronic system, records showed that an incident had been removed from the system the day of our assessment. We asked the registered manager why this record had been removed, and they told us that it was a duplicate record, however there was no other incident for this date. We could not be assured that incidents were always documented to ensure that appropriate action was taken.

There were ineffective processes to monitor, report and improve following incidents and accidents. Incidents were logged on an electronic system, however there was no oversight of this to identify patterns or trends. We asked the registered manager to provide oversight of accidents and incidents and they were not able to provide any documentation to show that they had oversight. Similar serious incidents re-occurred, including people being physically aggressive and targeting other people they lived with. We highlighted incidents of restrictive practice, which had not been identified by the registered manager. The registered manager did not have oversight, report or monitor the use of restrictive practices.

Although staff told us that they knew people well and understood their needs, we found this was not always the case. Care plans were generic and did not provide person centred information about people. When care reviews occurred these did not always highlight any on-going concerns. For example, relating to people and the suitability of their environment and housemates, which created negative outcomes for people.

The provider and registered manager had not worked collaboratively with partners to ensure people’s safety was managed, monitored and assured. Partners told us they were not aware of the risks we had identified: the provider and registered manager had not shared important information with them, or informed them about risks to people, or when people had been harmed.

There were no robust processes in place to ensure that risks were identified and managed in a proactive and effective way. The registered manager had not identified that assessments were not robust and had not identified that information from people's assessment had not informed where people lived, and who they lived with. The provider had not considered how people were supported to be part of their care planning. There was no evidence people had been involved in their assessment, care plan or review.

While the relatives we spoke to expressed that they were generally happy with the care their loved one received, our assessment found care did not meet the expected standards. When safeguarding incidents took place, action was not always taken by the manager to reduce the likelihood of the incident re-occurring - or report it to the local authority safeguarding team. People had not been given the appropriate support when they were involved in an incident of abuse, for example post incident de-briefs or wellbeing checks. Some people lived in a chaotic environment where they were subject to serious physical and psychological abuse, this included being spat at and physically harmed. The impact of on-going verbal and physical abuse from people living with each other had not been assessed or mitigated by the registered manager, and as a result people were harmed.

While staff we spoke with, including the registered manager told us they understood safeguarding, and their responsibilities to report abuse, however we identified this did not always occur. Staff failed to take immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way to share concerns about the risks of people living together, who were not compatible to do so. The registered manager told us they did not report incidents of abuse, because they knew the person did not intend to cause the other person harm. The registered manager failed to consider how this would impact on the person experiencing abuse.

We found that systems to identify and report safeguarding concerns to the local authority safeguarding team, and CQC were ineffective. The lack of effective systems, processes and practices meant that people's human rights were not upheld and they were not protected from discrimination. Care plans and incident documentation evidenced that physical intervention was used in response to some incidents of distress, however the processes to ensure this was implemented by a competent healthcare professional were not followed. There was no overarching system to review all safeguarding concerns and ensure appropriate action had been taken including notifying the relevant authorities. There was a lack of oversight and review of incidents by the registered manager and the leadership team.

Although relatives expressed that they were generally happy with the care, our assessment found care did not meet the expected standards. When people became distressed, staff did not always respond in line with best practice guidance, for example following the principles of RSRCRC, or positive behaviour support (PBS) guidance. During incidents people were 'escorted' to their room, which was not in line with PBS guidance. People did not have PBS support plans to inform staff how best to support them, and how to de-escalate any distress. Incident records showed that the care people received was inconsistent and not always in line with guidance or support plans. For example, during an incident of distress one person was administered some medicine to de-escalate their distress. There was no care plan to inform staff of actions to take prior to administering the medication. People received inconsistent support in relation to their epilepsy management, for example on one occasion during a seizure staff administered rescue medication to a person, however on another occasion when the seizure lasted longer, rescue medicine was not prescribed. This placed people at risk of avoidable harm.

Although staff told us they understood people well and supported them in a safe way we found this was not always the case. Incident records completed by staff were not sufficiently detailed to explain what happened during incidents of distress. For example, during one incident records stated, 'staff calmed them down and took them to their room.' There was no detail of how this was done, or why they went to their bedroom. Other incident forms make reference to staff 'intervening' during physical altercations between two people but without any explanation about how this was done. Staff were not trained, and there were no approved physical intervention techniques listed within people's care plans. The registered manager failed to identify and act on this. The registered manager lacked in-depth knowledge about the people they supported. For example, they were not able to confirm if someone was prescribed medication to reduce distress, or emergency rescue medication for another person.

There were not robust processes in place to ensure that risks to people were assessed and mitigated. Care plans we reviewed were not sufficiently detailed to inform staff how best to support people with complex health conditions. For example, one person lived with epilepsy, however their care plan was not sufficiently detailed to inform staff how to support them, and if they were prescribed any rescue medicines. When people could become distressed, guidance to inform staff how to support people to de-escalate or reduce their anxiety was not in place. There was not an effective system to review care plans and ensure they were sufficiently detailed and contained key information and guidance for staff. Audits we reviewed of care plans had not identified the widespread issues we identified.

Although relatives told us they were generally happy with their care, our assessment found care did not meet the expected standards. People had been subjected to physical intervention which had not been implemented following best practice. People were not always supported in the most appropriate ways when they became distressed. For example, people were taken to their room to de-escalate when this was not an approved technique documented within a PBS plan.

Staff and the registered manager lacked knowledge about physical intervention, when it was appropriate and proportionate to be used. Staff had used physical intervention on people when they became distressed, without the agreed processes implemented prior, or after incidents of distress. Staff had failed to identify and report these as incidents of abuse. Staff had not received training in physical intervention. There were no PBS plans in place for staff to follow, to inform them how best to support people in line with guidance on how to support people with a learning disability and autistic people. Although staff had received training, the effectiveness of this training was poor. Staff, including the registered manager failed in their duty to protect people from abuse. Staff and the registered manager failed to implement the Mental Capacity Act, and support people’s rights to make decisions about their care.

Processes to ensure that staff had the skills they needed were not always robust. The registered manager had not identified that staff has used physical intervention when supporting people, especially during times of high distress. Systems were not in place to identify this, and then ensure that relevant training and support was put in place to help staff.

On the first day of our assessment, the provider was unable to demonstrate that they had completed capacity assessments in relation to medicines. The following day, the registered manager sent us a document they said assessed people’s capacity, however this document stated that the providers assessors were not experts and not able to carry out capacity assessments. We were not assured that people’s capacity had been assessed around medicines was assessed in line with the mental capacity act. The provider was unable to demonstrate that people's ability to manage their own medicines has been assessed and considered to support their independence. There was no information provided to people in an accessible way to support their understanding about the medicines they were taking.

The registered manager showed a lack of understanding in relation to people's medicines. We asked the registered manager on 3 occasions if someone had rescue medicine in place to be given in the event of a seizure, and they told us the person did not have this medication. We found the person was prescribed this medication. Staff were aware of the medicine, and has received training, however without robust guidance in place there was a risk the medicine could not be administered when needed and as prescribed. Incident forms we reviewed showed that during one incident staff administered the emergency medicine even though the seizure was shorter than another documented seizure which the emergency medicine was not administered for.

Processes to ensure people received their medicines safely were ineffective. Some people received 'as and when' medicines, for example for pain relief, or emergency medicine to be given in the event of a seizure. There was no guidelines for staff to follow, including maximum dosage in a 24-hour period or when to administer emergency medicines in the event of a seizure. 'As and when' medication was not documented on the MAR. The registered manager could not be sure when or if 'as and when' medicines had been administered. Two incident reports stated that a person had been given 'as and when' medicine to help 'reduce agitation and behaviour that challenges.' This person did not have any 'as and when' medicine prescribed on their MAR to reduce distress. The registered manager told us this person used to have medication prescribed to support with their distress. It was not clear what medication had been given to this person. Medicine administration records were not clear and sufficiently detailed, for example explaining how many of the medication should be taken, or what the medication was for. There were no records kept for medicated creams or ointments. One person was prescribed a cream for a skin condition. There was no MAR for this cream, or information on how or where it should be applied. We asked the provider to send us medicine audits, however, the medicine audit they sent us did not identify any issues highlighted within this assessment.