Posa Care Solutions Limited

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.

This is the first assessment for this newly registered service. This key question has been rated 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 service was in breach of legal regulation in relation to the management of people’s medicines and the safe recruitment of staff.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness and honesty.

We found incidents relating to people’s safety were investigated and the actions taken and lessons learnt were comprehensively recorded. The registered manager stated people’s safety was a priority and they ensured measures were immediately implemented to help prevent further incidents. However, further development was needed to the systems used to analyse incidents and concerns, share learning opportunities and ensure all notifiable incidents were communicated to the Care Quality Commission when required.

The provider did not always maintain safe systems of care to ensure there was continuity of care, including when people moved between different services.

The provider had a pre-assessment process in place which enabled them to gather relevant information prior to care being provided. The provider worked with other agencies, people and relatives to gather information before people started to receive care and support. The registered manager met with the person and their family members or representatives to understand people’s support requirements and individual risks. However, there was limited evidence that people’s legal documents such as lasting power of attorney or resuscitation orders had been obtained. This meant people may receive inappropriate care as staff did not have access to legal documents outlining their preferences.

The registered manager and service manager had regular contact with people and knew their needs well. They spoke regularly with people’s families to help continuity of care and took account of the views of people and staff when reviewing people’s needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us staff were kind and caring and reported no concerns about their safety when being supported by staff. One relative said, “Yes he [person using the service] definitely feels safe with [name of staff member] now he is used to her.”

The registered manager and staff had received the level of safeguarding training appropriate to their role. Staff were aware of their role to report any safeguarding concerns to the registered manager who was the safeguarding lead. The provider’s safeguarding policy included essential information, including contact details for the local authority safeguarding teams.

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

People raised no concerns about the support they received and the management of their personal risks. Whilst staff and the registered manager knew people well, we identified gaps in people’s care records.

We found people’s care records detailing how staff should manage people’s risks was generic and lacked personalised information to guide staff. For example, safe and detailed working procedures were not documented to guide staff on how people should be transferred using a hoist and relevant slings.

Staff had access to risk management plans; however, we found some risk documents lacked personalised details on how staff should support people to reduce their individual risks such as risk of skin break down or the risks associated with catheter care. Possible signs of decline in people’s health relating to their risks and the contact details of key health care professionals were not consistently recorded. This meant staff did not always have access to personalised risk management plans to guide them on how to deliver safe, personalised and responsive support.

Whilst risk assessments had been completed, consent to delivering care and supporting people with cognitive impairments to manage their risks had not been completed in their best interest in line with the Mental Capacity Act 2005

The registered manager could not be assured people’s care needs had been met, as the quality and details of staff delivery of records were not consistent. Whilst the registered manager and service managers reviewed people’s needs with them regularly. However, updates and reviews of people’s care records as a result of the completed reviews were not always recorded or dated.

A newly appointed service manager acknowledged further development was needed in the quality and detail of people’s care records to help guide staff more effectively. The registered manager was responsive to our feedback and took immediate action to improve people’s care records. However, further time was needed to ensure the improvements would be sustained as the service expanded.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had identified risks relating to people’s environmental safety which was reflected in people’s care plans. The registered manager agreed to review their systems around staff lone working.

The provider did not always operate safe recruitment procedures, which put people at risk of being supported by unfit staff. We reviewed 4 staff recruitment files and found there was limited evidence the provider had explored staff’s health and employment histories including reason for leaving and gaps in their previous employment. This meant the registered manager could not be fully assured about the suitability and safety of conduct of staff.

The registered manager had trained and qualified as a trainer and had provided additional training to support staff’s online learning. Staff members received induction to the service which included shadowing an experienced member of staff.

Support and supervision systems were in place to observe and check staff practices and take action if further development was needed. For example, staff practices in managing people’s medicines and assisting people to transfer using a hoist were assessed by the registered manager; however, there was insufficient documentation of the assessments. This prevented the registered manager from demonstrating how they had assessed staff were compliant and delivered care in line national guidelines and the provider’s policies.

There were enough staff to support people. People and their relatives raised no concerns about the skills and reliability of the staff who supported them. The service manager had implemented a system to ensure staff were supervised and supported in line with the provider’s policy.

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.

People told us staff wore personal protective equipment (PPE) when providing them with support with personal care. Staff told us they had access to adequate supplies of PPE and were knowledgeable about how to use PPE and raise any IPC concerns with the registered manager. The provider had an infection control and prevention policy (IPC) in place.

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.

Staff did not have access to comprehensive medicine care plans to direct them in safe medicines management when supporting people with their medicines. The arrangements in place to manage people’s medicines such as who was responsible for ordering, collection and the named pharmacy was not recorded. The registered manager had not ensured accurate and complete records about people’s prescribed medicines and creams, associated risks and protocols for ‘as required’ medicines had been maintained. There was a lack of clarity in the management and administration of people’s medicines where there was shared responsibility. This increased the risk of medicine errors and omissions being made.

Staff had not consistently recorded the administration of people’s medicines including routine and irregular medicines. This meant the registered manager could not be fully assured people had received their medicines as prescribed and in line with the prescriber’s instructions. For example, one person required a daily transdermal patch (medicated skin patch) to be applied in different locations for 14 days, however, there was no system in place to ensure this was accurately applied.

Staff had been trained in safe management of people’s medicines. Competency checks of the safety of staff to administer medicines were completed by the registered manager; however, these checks were not recorded in detail.

These shortfalls placed people at significant risk of medicine related harm; therefore, we requested that the provider took immediate action to address our concerns at the time of our assessment. The provider was responsive to our request and has reviewed and updated people’s medicines care records. However further time is needed to ensure the safe management of people’s medicines will be maintained.