Access Dignity Care Limited Also known as Access Dignity

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 looked at all quality statements for Safe at this assessment. The service was not safe. This showed a decline since the last inspection. Risks were not robustly assessed, and people did not always receive their medicines safely and as prescribed. People did not always experience safe pathways of care. Safeguarding systems were not effective to ensure people were consistently protected from abuse and neglect. Improvements were needed to ensure safe environments, including in infection prevention and control. Leaders showed an open and responsive approach to making improvements following our feedback. However, at the time of our assessment, lessons were not learned from safety incidents to improve care for others. People were not always satisfied with visit times. Safe recruitment systems were in place. During our assessment of this key question, we found concerns about assessing risk, medicines management, safeguarding and staffing which resulted in a breach of Regulation 12, Regulation 13 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

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.

Feedback from people using the service did not reflect a learning culture. People told us staff did not understand their health conditions, which meant there was a missed opportunity for learning relating to people's specific needs. People did not always feel concerns raised were dealt with effectively or in a timely manner to reduce the risk of reoccurrence. A person said, “I speak to the office about the calls and the care workers, and I don’t think they take any notice. They tell me they will pass it on to the coordinator and someone will phone me, but they never phone me.” Another person’s relative told us they did not feel improvements were made when they raised concerns, stating, “I record everything by email, and I haven’t mentioned anything to you that I have not already reported to the office.”

Although leaders told us they were open to feedback and showed a willingness to make improvements, this had not been proactively identified prior to the assessment process. Feedback from staff and leaders showed there were inconsistencies in the approach to learning, as it was not modelled by the management team how safety events should be investigated robustly and learned from. Feedback from staff showed they did not always have the skills, knowledge, competency, or confidence to effect learning in practice.

The provider failed to adhere to its own policy and procedure on responding to incidents of harm, including consistently apologising to people when things went wrong. The provider could not always be open and honest, as there was limited oversight across concerns and incidents, and not all risks were identified and acted on appropriately to ensure safety. We identified a person who had sustained burns which required attention from the ambulance service. The provider had not completed risk assessment on smoking prior to this serious incident, despite this being a known risk. There was no evidence the incident was formally investigated, raised as a safeguarding alert to the local authority, or any lessons learned. This is despite daily care notes which showed staff had not followed basic first aid best practice and had placed the person at further risk of pain and infection. We raised our concerns with the provider and the local authority safeguarding team as a result.

We received mixed feedback from partners on the provider's approach to safe pathways of care. A professional who worked with the service told us, “Access Dignity worked for an adult who had complex mental health needs, and this involved 2 professional meetings and 2 best interest meetings. There was a representative at each of the meetings which helped to access a picture of how the adult was not accepting support and how strategies were tried to see if there could be a better outcome.” However, another professional confirmed the provider had not contacted them regarding a failure to meet a person’s basic care needs, placing the person at continued risk of harm.

Feedback from the provider showed they did not understand their role and remit in supporting people with skin integrity concerns alongside the district nursing team, and this had placed people at the risk of harm. Leaders acknowledged assessments and care plans were not fit for purpose and lacked significant information about people’s care needs. This had the potential to impact on information sharing with other system partners in an emergency, such as paramedics.

The provider did not demonstrate how they worked with people and other partners to establish and maintain safe systems of care, ensuring safety was consistently managed, monitored, and assured. The provider did not ensure continuity of care, including within its own staff team and also when people moved between different services. There was no effective process to monitor continuity of care staff, and no systems for ensuring this was in place for people it could significantly impact, such as those living with dementia. We identified some people who would be caused anxiety by changes to their care team but were not informed in advance of any changes. People were not supported to move safely through systems, including at the point of hospital discharge. We identified some instances where referrals should be made or advice sought from other professionals, but this had not happened. For example, a person’s daily care notes showed they had a bad cough and were struggling to breathe but there was no evidence this had been followed up by staff. Daily care records did not provide detailed enough information to support effective handovers and transitions into other health or care settings.

People gave mixed feedback on support by the service to access safe pathways of care, including support to access healthcare. A person’s relative said, “The other day a care worker spotted a pressure sore starting and told us straight away.” However, another person told us, “The care worker noticed [pressure damage] but hasn’t told me what I need to do or asked for help. I have bought an air cushion.” We advised the person to contact their GP. This meant people could not be assured of consistently safe transitions of care. Visit timings did not always enable people to access other professional support. Another person’s relative said, “We have a lot of professionals involved – OT, physio, nurses, social worker, and [professionals] come at 10am so [care visits starting at] 9.30am is too late to get [person] ready.”

Although confident to report concerns to the management team, staff could not always tell us how they would escalate safeguarding matters to external authorities such as the police, local authority or the CQC. The registered manager told us they did not know all safeguards had not been notified to the CQC as required by law until this was information was requested during our assessment. This placed people at the risk of harm. The registered manager confirmed they would strengthen safeguarding systems at the service as part of their action plan.

People told us they generally felt safe with their regular care workers, and staff were kind. A person’s relative said, “We just have 1 call a day for personal care; we are happy with what we have and [person] is safe with the care workers.” However, some of the issues described by people could place them at the potential risk of harm, including due to lack of confidence in the service. A person told us, “I have spoken to my social worker, and we have paused care because I am not happy with the care I have been getting. My [family member] is going to do the care while they sort out the funding and the difficulties and the social worker is going to come back to me.”

There was no effective oversight of safeguarding matters by the service. This meant not all safeguarding concerns had been referred appropriately to the local authority for investigation. We asked the provider to make an individual safeguarding alert for 1 person who we identified to be at significant risk from review of their records. We also raised an organisational safeguarding alert to the local authority regarding poor assessments and the impact on people, including the risk of potentially avoidable harm. There was no process or system to analyse safeguarding matters to identify themes and trends, learning and reduce the risk of reoccurrence. Safeguarding concerns showed similar patterns, including self-neglect and pressure injuries. The provider did not respond to safeguarding matters by following its own policy, and on 1 occasion acted in response to an allegation of theft before seeking police advice.

People were not empowered to make decisions about their own care. Others were not supported when making choices which could be considered unwise, placing them at the potential risk of harm. People told us they could not always rely on the service to work with them to manage known risks, particularly in relation to staff knowledge and understanding of individual healthcare conditions. A person’s relative said, “The quality of care is not amazing. [Access Dignity] allocated us a time, we weren’t given a choice and they allocated us 9.30am for breakfast but [person] is diabetic and some days [the care workers] haven’t come until 10.15am” and “[Care worker] is very pleasant but I’m not confident that they would know if there was a diabetic issue, they wouldn’t recognise it.” Another person said, “Sometimes [the care workers] have trouble knowing what to do, I help them to help me, and I try to help them to understand Motor Neurone Disease, I tell them about it and how it is affecting me. I’m not sure about their training.” Another person's relative said, “I don’t think [the care workers] are very well trained. They seem to be OK with dementia but [person] has Huntington’s Chorea and they don’t understand the uncontrolled movements. I’m not sure the care workers are aware of [person's] diagnosis or have had any training."

Processes were not effective in assessing risks, and we identified multiple people's care records which were incomplete, contradictory, or inaccurate. There were multiple areas of concern which were not identified and addressed to mitigate risk in people’s care records, including catheter care, medication, skin integrity, choking, allergies, malnutrition and dehydration, and the potential impact of people's specific health needs. For example, 1 person's care records stated they were only 'at risk' of developing a pressure ulcer, whereas staff told us the person did have a pressure ulcer and records showed the person in pain. These widespread issues had not been identified by the provider’s own auditing and oversight systems. The provider voluntarily self-suspended the service following our feedback, so widespread process failures relating to risk management could be addressed for people already using the service, prioritising those with the highest level of risk. This included re-training staff on completing care assessments and planning.

Where staff and leaders own knowledge of people’s individual conditions and potential impact on the person’s life was lacking, this impacted on their ability to support people to manage risks safely. Staff told us they read people’s care plans and during the visit would work systematically through the tasks identified for that person. Where staff were unable to complete a task because the person had refused, for example personal care or taking medication, this was not escalated safely. Although staff said they would record it in the daily notes and at times reported it to the office, the registered manager acknowledged there was no effective follow-through. Staff were not aware of risks associated with individual healthcare conditions. For example, 1 person was living with Multiple Sclerosis (MS) but this was not recorded in their care plan, and none of the staff we spoke with were aware of this diagnosis, including the management team. This meant known potential risks associated with MS such as swallowing difficulties were not risk assessed.

We received mixed feedback from people using the service, with some people reporting they felt safe and were happy with their visit times, but others dissatisfied with their inability to access the electronic call monitoring app to use technology to check care visit records. A person told us, “[Care workers] stay the full time, they are hardly ever late and if they are they phone or text because I like them to do that. They do everything I want them to do.” However, a person’s relative told us, “I have asked for access [to the app] because I need to see the records, especially as we have a lot of people involved, but [Access Dignity Care Ltd] just don’t come back to me.” Another person’s relative said, “[Staff] put everything on their phones, they are always on their phones. I don’t have any access to that information, and it has never been offered.”

Whilst care visit times were logged on an electronic app accessed through care worker’s mobile telephones, there was no ‘real time’ monitoring of this system and no alerts set up to tell staff quickly in case there had been a missed visit or missed medication. Leaders did not demonstrate an understanding of their electronic call monitoring system functionality or how to use this effectively to keep people safe. The registered manager told us they would make improvements in this area.

The provider did not always detect and control potential risks in the care environment. Although there were systems in place such as electronic call monitoring and environmental risk assessments, processes were not always sufficiently robust for ensuring equipment, facilities and technology supported the delivery of safe care. We identified 1 person’s care plan stated they had oxygen in their home, however there was no fire risk assessment relating to this or any further information for staff other than instructions not to ‘tamper’ with it. There was also no information on flammable emollient creams, which can still pose a risk even after being laundered. Whilst moving and repositioning assessments did record equipment in place, there was no robust information included on servicing, who was responsible for this, or signs of wear for staff to be aware of.

Safe recruitment systems were in place for staff, including via Home Office Sponsorship Licence processes. Checks included referencing and with the Disclosure and Barring Service (DBS). Interview processes required improvement to show how the provider explored staff have the skills and values required for the role. Where the provider had appointed an assessor and compliance officer, or delegated tasks to others, there was no effective process in place to check staff competency. The assessment of a person’s needs is crucial to the provider in being able to demonstrate they have enough qualified, skilled and experienced staff to offer safe care and support. Shortfalls in the assessment process were not independently identified by the provider, which impacted on staffing. Electronic call monitoring data was checked by a specialist CQC team, and showed visits punctuality and duration were satisfactory. However, some people provided feedback they were not happy with allotted call times, so whilst this data showed staff were logging in correctly to the times the provider had scheduled, these times did not always meet people’s needs and preferences. The registered manager had already commenced work on plotting visit times at the time of inspection, and explained this was an ongoing process.

People described a mixed experience in relation to staffing. People were not always satisfied with visit times, and did not feel staff were trained well enough to support with specific conditions. However, there were no reported missed calls. A person told us, “The times aren’t all the ones I want. In the evening [the care workers] come at 7.30pm which is much too early and I really want 8.30pm. I’ve asked but nothing changes” adding, “Generally they come on time and my good carers phone me if they are going to be late.” Concerns were raised about staff development, and the impact on people whilst training new staff. A person's relative told us, "The care workers do not understand Parkinson’s. They rush [person], which increases [person's] anxiety and because they keep changing care workers [person] has to explain to new carers what they need and that is very difficult and increases [person's] anxiety too” adding, “At 1 point there were 3 carers coming in, 1 shadowing and that was simply overload and far too much for [person] to cope with." There were also comments on staff communication barriers. A person’s relative said, “The first time someone came to do breakfast they didn’t boil the kettle for a cup of tea. [Care worker] went to fill the cup from the tap and put a tea bag in it – it was lucky I was here. Then [care worker] went to dish up yoghurt and went to put it in the dog’s bowl which had been draining on the side.”

Staff told us they received supervision and felt supported by the supervisory and management team. However, shortfalls in the service showed some staff required additional supervision and training to fulfil their role. Where care staff did not have the skills and training to meet people’s individual needs this put people’s safety and welfare at risk. For example, we identified the provider had advertised on the company website as a service providing palliative care, but staff did not have any specialist end of life care training. The registered manager acknowledged this and told us this would be sought for staff. The training manager completed competency assessment forms and training feedback, but needed more detail on actions taken to support development. This included in key areas, such as with communication barriers.

We received mixed feedback from people about infection prevention and control (IPC). A person’s relative said, “[Care workers] wear PPE and put on masks and gloves and throw them away in the right bins when they leave.” However, another person’s relative said, “[Care workers] don’t wear masks, they never wash their hands, but they do wear gloves and throw them away when they leave.” Whilst it is not current government guidance for care workers to wear a face mask, people may choose to ask visitors to their home to do so. However, a person’s relative said, “We asked for PPE especially a mask, when we had a meeting. The regular [care worker] has 1 and wears it but a [new care worker] turned up yesterday and had nothing, no PPE. I haven’t noticed hand washing.”

Staff told us they received training in infection control and were given access to enough PPE. A staff member told us they always carry a supply of hand sanitiser, face masks, aprons and gloves. Management told us spot checks to ensure staff were wearing correct PPE were carried out. However, staff could not always explain good IPC practice when supporting people with injuries, to reduce the risk of infection when providing basic first aid.

The provider had infection control policies and procedures in place. However, although compliance checks were completed, feedback from people using the service indicated staff did not consistently follow good hand hygiene practices. Complaint records showed an instance where a staff member had gone to provide care to a person at known risk of respiratory illness whilst unwell, and another person had complained they had been accidentally scratched by a staff member wearing artificial nails. Artificial or painted nails provide a breeding ground for bacteria and make hand hygiene less effective. Whilst the provider took action to address these individual concerns, this did not show good IPC processes were always embedded in practice. Care records did not always cover IPC concerns robustly, including a lack of guidance on reducing the risk of cross-infection when bathing eyes or administering eye drops.

The provider told us there was a company policy for staff not to provide personal care to areas of broken skin, even if this was not considered to be a wound falling under district nursing supervision. This placed people at risk of pressure injuries and infection and had led to involvement of the local authority safeguarding team on multiple occasions. The provider has since changed the company policy following our feedback. Staff could not tell us how they proactively supported people with pain management, to ensure they felt comfortable enough to receive support with re-positioning or with personal care.

Although staff received medication training this was not well embedded, and we received mixed feedback from people using the service. A person told us, “[Care workers] do my tablets, every morning and evening they remind me. [Care worker] will order my tablets too – they deserve 5 gold stars for the help they give me.” However, another person said, “[Care workers] used to do my medicines. They would stand there for 10 minutes trying to work it out, so I phoned the office and told them I was going to do my own medicines. They had no idea, the care workers.” Another person’s relative told us staff would not administer their prescribed medication as they confused the date of issue with the date of expiry, which led to their medicines being disposed of.

Medicines were not always given safely and as prescribed. Poor oversight of medication systems put people at risk where shortfalls were not being identified and acted on within a timely manner. This was acknowledged by the registered manager, who following feedback said they would review their systems and increase auditing to ensure safer oversight. People were at risk of constipation, pain, and discomfort where bowel medicines were not being administered as prescribed or monitored effectively. We identified 1 person who had not received their bowel medication as prescribed by the hospital discharge team. This was not identified by the provider prior to our feedback. There were no body maps in place to guide staff on the application of topical creams or transdermal patches. Record keeping for failure to apply prescribed creams was poor. There was no guidance for staff on the safe application of eyedrops, and we found the risk of potential medication overdose was not always well managed. The provider was not following its own policy and procedure on medication practice, and people's Medication Administration Records (MARs) were not always clear or up to date.