Pacific Care Services Limited - Isle of Wight

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to risk assessment and medicines management.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had systems for reporting and investigating safety events, including accidents and incidents. Staff understood how to escalate concerns and felt able to raise issues. Lessons were learnt from incidents, and staff described how training and feedback helped them improve practice. However, some staff reported that follow-up after raising concerns could be inconsistent, and safeguarding reports were sometimes discouraged from being documented, which could undermine transparency. A staff member said, “You always learn a lot, each time there is an incident you learn how you could do something better.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Processes were in place for safe transitions when people started care, including assessments and involvement of families and professionals. A family member told us, “They came and asked what I wanted and did a care plan and they have been back to review it.”

Staff confirmed they were usually introduced to new people and had access to care plans via an app. However, care staff did not always have full information before initial visits, and inconsistencies were found between emergency information for other health professionals (grab-and-go sheets) and medicine administration records, which could pose risks during emergencies.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. An allegation of abuse was investigated internally without referral to safeguarding or notification to CQC, contrary to policy. Whilst the investigation had not substantiated the concerns the provider’s procedures had not been followed. There remains a risk that safeguarding concerns may not always be identified placing people at risk of harm.

Care staff had completed safeguarding training and felt confident to raise concerns. A staff member told us, “I would record it first and put it on a body map and on [the provider’s electronic care system]. Notify the people in charge by calling them and put details in the notes.” People and families said they felt safe, and external professionals did not raise safeguarding issues. A family member said, “They [care staff] are all lovely… I do feel safe with them.”

The provider had not ensured all risks for individual people were assessed and plans in place for staff to manage and reduce risks. Risk assessments were not consistently in place for significant health needs such as diabetes, epilepsy, catheter care, choking, and blood-thinning medicine. Some people lacked environmental risk assessments, and there were gaps in risk management for outings in staff cars where essential documentation relating to staff car safety was not available. There was also conflicting information about risks within different care related records and documents for individual people meaning risks may not be consistently responded to by care staff. Although we did not identify harm had occurred this meant people and care staff were exposed to avoidable risks.

The provider did not always detect and control potential risks in the care environment. Home environments were considered during assessments, and some environmental risk assessments were completed. However, not all people had environment risk assessments, and responsibilities for fire safety checks were unclear. Staff were trained to use equipment safely, and the provider could access specialist equipment when needed.

Although the provider ensured there were enough qualified, skilled and experienced staff all formal pre-employment procedures had not always been completed. Care staff told us they felt supported although formal supervision and support sessions had not always occurred. Some feedback occurred informally: however, formal supervisions had not consistently been completed.

Recruitment checks including full employment history and evidence of conduct in all previous work with vulnerable people were incomplete for some staff. People told us and records confirmed, that continuity of care and visit times were variable, and some staff lacked travel time between calls.

People and families said staff were generally well-trained and competent, and most felt visits were timely. Staff confirmed training was helpful and included shadow shifts. A staff member told us, “We receive all regular training and complete all this yearly such as moving and handling. I think it does give me the skills I need.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had received infection control and food hygiene training and had access to Personal Protective Equipment [PPE] such as disposable gloves and aprons. People confirmed PPE was used appropriately. For example, a person using the service said, “They [care staff] all wear their gloves and aprons.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were administered by staff who had received training, but competency assessments were not completed before staff undertook this task. Care plans lacked detail about medicine risks, and emergency information sheets [grab-and-go sheets] contained incorrect dosages and inconsistencies with current medicine administration records.

Systems to ensure medicines were always available for people were generally effective. However, there was a long delay in establishing why a person no longer had stock of a specific medicine which, if this had been required, may have impacted on their health. Information about ‘as required’ medicine [PRN] guidance was unclear. A person told us, “They [care staff] make sure I have taken them all.” A staff member said, “We remind carers to read the prescription boxes and inform the office of any changes.”