Premier Care Limited - Specialised 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 safe care and treatment and staffing.

This service scored 34 (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 consistently 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 and processes had not been used correctly to ensure incidents and accidents were recorded and responded to appropriately. The provider was unable to provide us with any documentation related to incidents and accidents. Staff told us they were trained to report any concerns they had and recorded them on their handheld devices. Staff had not followed the correct processes to ensure they were logged centrally. This put people at risk of harm as we could not be assured the right actions were taken to keep people safe.

Staff reported poor support from office staff in relation to accidents, incidents and safeguarding concerns until recent changes were introduced. They told us, “[Office staff] were not responsive at all so I reached the point where I would not contact [office staff] at all” and “Staff safety has been compromised by poor management of accidents and incidents. Situations would escalate and put staff at risk. These situations could have been managed. We could not meet some people’s needs.”

The provider told us measures were taken during the assessment to ensure the correct processes were in place.

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.

Referrals into the service had been suspended by the local authority since May 2025. All care plans were in the process of being reviewed in partnership with the local authority. The provider acknowledged there had been shortfalls in their referral and assessment processes. People’s needs had not been fully understood, care plans had not been reviewed, and risks had not been escalated as required.

The local authority commissioning team and the safeguarding team had raised concerns about safeguarding processes prior to the assessment. They were not confident information was always shared when required. Improvements were made during the assessment to ensure safeguarding processes were being used correctly.

We did not see any documentation to support people if they needed to go to hospital. Hospital passports are used by services to ensure all relevant information about the person’s care and support needs are shared. The provider agreed to put these in place.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

Staff had access to policies and procedures in safeguarding. Staff were supported through their induction and training to understand their safeguarding responsibilities. We discussed safeguarding with 10 staff and checked their learning in practice. They understood their responsibilities and how they should report concerns. They told us, “I have received safeguarding training, including recognising signs of abuse and reporting concerns.”

The provider was unable to provide us with any documentation related to safeguarding. The systems and processes to manage safeguarding were not established in the service and we could not be assured people were being kept safe.

Professionals who worked with the provider were not confident in the organisations ability to recognise and manage safeguarding matters. This had been an ongoing concern, for a number of months and had been raised by the Local Authority with CQC prior to the assessment.

Staff told us, “I record everything on my call logs on my phone. In the past the management did not respond. For example, [Tenant]was using [Illegal drugs] and I reported this and the management, they were not responsive. [Tenant] self-harms and they said to just make him an appointment with the doctor. I am not aware of it being raised as a safeguarding.”

Measures were taken during the assessment to ensure the correct processes were in place and the provider was working closely with the local authority to correct this.

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.

Risks to people were not assessed and managed appropriately. There was no evidence in people’s care plans to demonstrate they had been involved in discussions about risk. Risk assessments were incomplete and did not provide staff with sufficient guidance to support people to stay safe. This increased the level of risk people were exposed to.

There was no evidence people had been supported to take positive risks to help them achieve their goals.

The provider acknowledged staff did not have the appropriate training to carry out this role effectively and safely. Staff told us, “They need to be redone. I think staff need to be trained to do it properly. Previous office staff have written them. They need to be more collaborative” and “They need tweaking as they are not accurate enough. Different people have been writing them.”

Plans were in place to ensure staff had an enhanced level of training. Training would also be provided to ensure staff could respond appropriately to behaviour that communicated a need, emotion or distress.

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 have effective systems in place to ensure people’s home environments were safe. Records for legionella, electric and regular checks of fire safety equipment were inconsistent and incomplete. We reviewed fire risk assessments in two of the properties we visited; areas of concern had been identified, and actions were required to address the shortfalls within a specific timeframe. The provider was unable to provide evidence of any actions being taken.

There were multiple issues impacting on safety at the properties we visited. A new electrical socket needed to be fitted to remove a trip hazard in one property. Staff said they had reported it a month ago, but nothing had happened. I reported this to the deputy manager who said the work would be completed the same day or the following day. The cellar door in the kitchen in one property was not locked. Staff said it was very unlikely the current residents would go into the cellar. The stairs leading down into the cellar was a potential trip hazard and it was also a dumping ground for various building materials. It was also exposed to the outside elements as the wall under the metal grid outside was not sealed. This was also reported, and we were told a lock would be fitted. Both tasks had not been completed when we returned the following week. Action was taken to remedy the shortfalls by the end of the assessment.

Renovation of all the properties was required to bring them up to a good standard. Work had started but there was no clear timescale for this to be completed.

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.

The provider operated a thorough recruitment process. Checks were undertaken on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining two references and carrying out a Disclosure and Barring Service (DBS) check. DBS checks help prevent unsuitable people from working with vulnerable people.

The provider acknowledged staff did not have the right level of training to meet the needs of people in the service. This placed people at increased risk of harm. This included training for learning disability and autism. This has been a legal requirement for all registered providers since 2022. Plans were in place to ensure staff had the right level of training.

There were shortfalls in the induction process. Supervisions, spot checks and shadowing had not been recorded. We could therefore not be assured new staff had received appropriate support before starting in their roles. This placed people at increased risk of harm.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

People were supported by staff who had received training in infection prevention and control. The staff we spoke with understood their responsibilities. They told us, “Yes, I am quite cautious. I wear gloves for medicines, cooking, personal care and yes, I change gloves between tasks” and “Yes, I have to go to the office to get gloves, and we would change them between every task.”

The houses we visited were not clean. The provider agreed to implement cleaning schedules in all houses where people will be supported in line with their care plans. The provider told us weekly inspections of communal areas would also be introduced.

The service did not always ensure medicines and treatments were safe or consistently met people’s needs, capacities and preferences. There were shortfalls in record keeping and oversight of medicines.

Medicines were usually stored safely in people’s rooms. However, at one location, medicines were not stored securely and this was discussed in detail with the provider.

A new electronic medicines administration record (eMAR) system was introduced in September 2025, which included systems for recording and managing time-critical medicines, when required medicines, allergies and body maps. However, issues with staff rotas and rostering were cited as a contributing factor to a very high number of alerts for missed doses as staff could not access the system to make the appropriate records. These alerts had not been promptly investigated to confirm whether medicines were administered or missed for valid reasons and this meant an accurate record of medicines administered was not being maintained. The provider told us after the inspection immediate action had been taken to investigate the alerts and steps were being taken to improve systems to prevent it happening in the future.

Records of medicine’s receipt and disposal were made for medicines in 3 locations but in 1 location these were not being made. Plans about how to give when required (PRN) medicines were available but these sometimes lacked detail therefore there was a risk people’s medicines would not be given consistently.

We found 2 short-dated medicines were not dated upon opening so there was a risk they might be used past their expiry date.

For 1 person who was self-administering 2 medicines we found no records about how they were being supported and the eMAR system did not list that these medicines were currently prescribed.

The provider told us medicines audits had been conducted prior to the eMAR rollout, but no audits were available during the assessment. Staff training was described as a mix of face-to-face and e-learning, but we found a high number of competency assessments were overdue their completion date.