Your Priority Healthcare Limited

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• 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 service. This key question has been rated 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 safe and effective 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 listen to concerns about safety and lessons were not learnt to identify and embed good practice.

Feedback from people and stakeholders had not always been acted upon or responded to in a proactive and timely manner. For example, the local authority had completed a Provider Assessment and Market Management Solution (PAMMS) in November 2024, an online assessment tool used to help the local authority assess the quality of care delivered by providers of social care services. This had resulted in widespread and significant shortfalls being identified many of which remained at the time of this inspection. This demonstrated a poor culture regarding learning and acting upon recommendations. There were no recorded safety incidents to review as part of this assessment.

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.

There was evidence to show that people’s needs had been assessed prior to using the service to ensure the service could meet those needs. One relative who provided us with feedback told us this assessment had been thorough and that the registered manager had ensured staff were familiar with their relative’s needs prior to delivering care.

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 had processes in place to help protect people from the risk of abuse and this included ensuring staff had received training in safeguarding, and an appropriate safeguarding policy was in place. Staff told us they were familiar with the policy and knew how to report concerns. A safeguarding audit had been completed. However, these had been completed infrequently and failed to demonstrate a meaningful audit of the safeguarding systems had taken place.

The provider did not work well with people to understand and manage risks. Whilst in practice we found no evidence to show people had been harmed, risk assessing was poor and failed to either identify risks to people and staff or adequately manage those risks. This placed people at risk of avoidable harm. For example, whilst moving and handling risk assessments were in place, these only recorded how a person completed moving and handling tasks rather than identify the associated risks and apply measures to mitigate them. In addition, we saw that, a risk assessment for a person diagnosed with diabetes failed to give staff information on symptoms that may indicate the person’s diabetes was unstable and therefore making them unwell, and the actions they needed to take in response.

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

Whilst the provider had completed risk assessments on people’s homes, these were poor and failed to adequately identify the risks and mitigate them. This placed people, and staff, at risk of harm. For example, the assessments failed to consider risk factors such as the external environment of the person’s home, fire management, and risks associated with utilities and the potential need to isolate these in the event of an emergency.

Whilst the provider ensured there were enough staff to meet people’s needs, they had not made every effort to gather all available information to confirm staff were of good character. Nor had the provider ensured staff received full support, supervision and development.

Whilst we found no evidence to suggest staff were not appropriate to work with vulnerable people in the UK, the provider had not taken every opportunity to assure themselves of this. For example, application forms were incomplete and for the recruitment files we assessed, there was not enough evidence to demonstrate people had performed well in previous roles working with vulnerable people. The provider could not demonstrate that recruitment was safe and fair as only one person had completed interviews and robust records had not been made on potential staff member’s responses and how these compared to other candidates. Furthermore, the provider had failed to maintain a copy of staff member’s up to date immigration status.

The provider had not managed the risk of infection and/or detected and controlled the risk of it spreading.

Despite people who used the service being at higher risk of infections due to their individual needs, the provider had not assessed this risk, nor mitigated it. For example, some people had multiple risk factors for infections due to their diagnosed health conditions and age. Despite the provider having an infection prevention and control policy in place that stated all people who used the service should be assessed for infection risk, they had failed to adhere to it.

The provider did not make sure medicines and treatments were safe. Whilst we found no evidence people had been harmed, we saw that the provider was not administering medicines in line with their own policy or best practice. For example, staff were administering prescribed topical medicines without any form of medicines administration record (MAR) chart or body map in place. Whilst the care plan gave staff some directions on how to administer these medicines, the provider’s policy stated having a MAR chart in place was best practice. Furthermore, the National Institute for Health and Care Excellence’s (NICE) best practice guidance on managing medicines for adults receiving social care in the community states providers should have robust processes in place for recording a person’s medicines including topical medicines.