Pro Healthcare Services

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed safely.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems to record, investigate and learn from incidents were ineffective. For example, accidents and incidents were not always recorded or reviewed, and leaders were unaware of events such as falls and environmental incidents shared by relatives. A relative told us, “[Person] had a fall and nobody told us about it.”

Accidents and incidents were not analysed for patterns and trends to support continuous learning and improvement.

Audits and governance systems had not identified widespread concerns relating to medicines, risk assessments and missed or late visits. Although some improvement actions were described by the provider, there was limited evidence these had been implemented or embedded in practice at the time of our assessment. This meant opportunities to improve care and reduce risks were often missed.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems for coordinating and monitoring care were not always used effectively to provide assurance that care was delivered safely and consistently. Arrangements for delegated clinical tasks such as clinical care were not clearly documented, and there was limited evidence of oversight and review processes, particularly where responsibility for care was shared with other healthcare professionals.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

We found the system in place to manage late, and short visits was not working well. Instances of late visits were recurrent and the systems the provider had in place were not always effective in identifying and addressing these. Due to the widespread nature of these concerns and potential impact on people, we shared our concerns with the local authorities safeguarding teams.

There was a safeguarding policy in place, and staff were trained in safeguarding people. We reviewed examples where safeguarding concerns were raised; the provider had taken the appropriate action by reporting these to the local authority. However, we found examples where safeguarding concerns had not been notified to CQC. This was completed by the provider after we requested it.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were either not in place when we requested them, or were not detailed and person centred. Risk assessments for areas such as falls or moving and handling were missing or lacked detail. This staff did not have clear guidance on how to manage risks safely.

Risks linked to people who were receiving clinical care with their catheter were not described in their risk assessments or care plans. There was no evidence of regular reviews of care completed by those with responsibility for clinical oversight.

Although the provider stated they were reviewing risk documentation, these improvements were not yet embedded. This placed people at risk of unsafe or inappropriate care.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider did not always have good oversight of the safety of the equipment used to transfer people. Some people using the service required staff to use a hoist to safely move them. When requested, the registered manager and nominated individual could not provide us with the details of when the equipment used by staff to lift and move people had last received their safety check, under the Lifting Operations and Lifting Equipment Regulations. We requested this information several times during and after our assessment, and we did not receive evidence to assure us all equipment used to move people had passed the required checks; we shared this information with commissioners of care.

Although some environmental risk assessments were in place, the lack of reliable oversight and assurance meant people could be exposed to avoidable risks.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Call monitoring arrangements were not managed effectively. People and relatives told us care visits were not always completed on time and staff did not always stay for the full duration of the care visits. Information reviewed as part of this assessment on care visits planned and completed, as well as late visits showed several visits had been completed over 30 to 45 minutes of scheduled time, to people across several areas. We reported these concerns to the relevant local authorities safeguarding teams due to these issues being widespread and the potential impact on people. After we raised our concerns, the provider told us they put new systems in place to monitor this area.

Feedback from people and relatives consistently highlighted examples of lack of continuity of staff providing care. A person stated, “I feel safe when my regular carer is there. There are so many new carers that it is difficult to know who is coming.”

Our review of training showed some gaps in mandatory training and competency records; however, additional evidence provided by the service indicated training requirements had been completed or were underway, with competency assessments evidenced for staff members reviewed.

Most aspects to recruitment were managed safely but we found concerns with the lack of evidence of origin of references. We found examples of staff's visas having expired, but the provider submitted evidence showing these staff had the right to work in the UK as applications for the renewal of their visas were ongoing.

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 demonstrated an understanding of infection risks in specific tasks, such as catheter care, including recognising signs of infection and when to escalate concerns.

Staff had up to date training in infection and prevention control practices.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not managed safely. We found evidence of unsafe practices, including the unsafe dispensing of medicines and failures to administer time-critical medicines as prescribed.

Records showed medicines were not always given at the correct times and there were also gaps in medicines records; audits had not identified these issues.

Staff had completed competency assessments; however, this had not been effective as we found examples of unsafe practices.

We discussed our concerns with the provider and said they would take action; however, systems in place to monitor and ensure safe medicines management were not effective.