Allot Healthcare Services York

Significant concerns were identified regarding the provider’s ability to assure themselves people consistently received safe, effective and well-coordinated care. The service had experienced prolonged difficulties accessing its electronic human resources and care management systems and was in the process of transferring information to a new system. As a result, records were fragmented across electronic and paper systems and inspectors experienced considerable difficulty obtaining information requested during the inspection.

Leaders were unable to readily demonstrate effective oversight of care, staffing and governance arrangements. Records relating to incidents, safeguarding concerns, medicines, pressure care, seizures, repositioning and other areas of risk were incomplete, disorganised or had not been consistently reviewed and followed up. We found examples where concerns relating to wounds, skin integrity, seizures and medicines had been recorded but were not reflected within incident management or governance systems. This meant people were placed at risk of harm because leaders lacked effective oversight of incidents, risks and quality concerns, reducing their ability to identify issues promptly and take action to keep people safe.

People, relatives and staff repeatedly raised concerns about communication, continuity of care and timekeeping. Several relatives described difficulties contacting the office, receiving support from familiar carers and not being informed of changes to visits. The provider's own surveys, complaints records and audits identified similar themes, including staff lateness, inconsistent staffing and communication failures. While leaders had recognised these concerns, inspection evidence demonstrated governance arrangements remained ineffective and had not resulted in sustained improvements for people. Significant discrepancies were identified in staffing information, recruitment records and monitoring systems, reducing assurance that risks were being effectively managed.

Although care plans were often detailed, they were not always current, consistently implemented or accurately reflected in the electronic information available to staff. We could not be assured people had been involved in these or in any subsequent reviews. In addition, information in care plans was not always accurately transferred to the electronic system staff used to understand the care people needed.

Overall, weaknesses in leadership, governance, record keeping and quality assurance meant the provider could not demonstrate people consistently received safe, effective and responsive care. Leaders had identified areas requiring improvement and had plans to strengthen systems, but these changes were not sufficiently embedded at the time of the inspection.

We identified 5 breaches of regulation relating to person-centred care, safe care and treatment, staffing, fit and proper people employed, and good governance. Risks to people were not always managed safely, staff were not recruited safely or deployed effectively, care records were not consistently person centred and governance systems had failed to identify or address concerns.

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