Prominence Care Group

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 provider was in breach of legal regulations in relation to people’s safe care and treatment, safe staffing arrangements, staff training and supervision and safeguarding people from harm and abuse.

This service scored 47 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had a system in place for staff to record any accidents or incidents. The registered manager kept a log of these including any follow up actions identified. For example, referring people for medication reviews following falls. Managers told us they discussed incidents with staff as part of a debrief and learning, and staff were encouraged to make suggestions for improvement.

However, where required actions had been noted, these had not always been incorporated into people’s care records. For example, following an incident, the action log stated the kettle should always be left empty, however, this was not reflected in the person’s assessments or support plans. Risk assessments had not always been undertaken or reviewed following incidents; therefore, it was unclear if lessons were always learnt or whether actions identified were fully embedded.

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.

The registered manager told us they were in the process of developing hospital passports for people. This is a tool used to document key and vital information about people, to share with health professionals in an emergency, such as paramedics, or for hospital staff should they be admitted to hospital. Whilst these were being developed, they said they were able to share health and care information promptly if needed. However, we found care records did not always contain up to date or sufficiently detailed information about all aspects of people’s care and support needs, therefore there was a risk accurate information may not be provided in an emergency situation.

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 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.

Whilst the provider had a safeguarding policy in place, the registered manager had not always followed procedures to protect people from the risk of abuse and harm. We were informed by a relative about a potential safeguarding concern, which staff had not reported through local procedures. We confirmed the local authority and police had subsequently been made aware of these concerns.

Details relating to the management of people’s finances and potential risks, were not adequately assessed and recorded within their care records, to help protect them from the risk of financial abuse. We asked to review the provider’s policy for supporting people to with financial management; however, this was not provided.

The provider had not identified and recorded where some restrictive practices were put in place for a person. There were no records available to demonstrate the legal justification or whether discussions had been held with the person about the reason for the restrictions. The local authority was in the process of reviewing this person’s care needs.

The provider offered safeguarding eLearning to staff; however, several staff were yet to fully complete this required training. The registered manager said they were encouraging staff to complete these modules. Staff said they understood their role to safeguard people and felt able to raise concerns with managers should they need to.

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 not always undertaken or were not sufficiently robust. Whist staff told us managers updated them about aspects of risk, staff supporting a person with complex health needs, did not have all the information they needed to help manage risks safely. For example, in relation to; behaviours of concern, accessing the community and the risk of self-neglect. An incident had occurred and whist there was no harm; this may have been mitigated if staff had followed guidance previously provided by a health professional, which was not included within the person’s support plan.

The registered manager told us required improvements to risk assessments had been identified during an internal ‘mock inspection’ and actions were planned to address this. Where there were specific risks identified, the local authority was working with the provider to address these.

The provider did not always detect and control potential risks in the care environment.

The registered manager had not ensured potential risks in relation to the environment had been fully assessed, to support the safety of people and staff. For example, in relation to the safe use of kitchen equipment. Where a concern had been identified in relation to a person’s access to sharp objects, staff had not always followed the recorded guidance. The registered manager told us this was because the risk had now reduced, however, the records had not been updated to reflect this.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

The provider’s processes were not sufficiently robust to ensure required staff recruitment checks were undertaken, as we found gaps in these checks. For example, they had not always ensured adequate references and full employment histories were recorded. The provider used an external agency for these checks; however, the provider’s records were not sufficiently robust to provide assurance all required checks had been undertaken.

The registered manager told us staff were provided with induction and eLearning training. Staff confirmed they received this. However, records were not available to demonstrate what the induction consisted of. The provider was in the process of rolling out a new induction booklet. The registered manager kept a training matrix, which showed some staff had not completed all required training modules. They told us they had been encouraging staff to complete these.

The registered manager had arranged bespoke training in relation to certain health conditions, to help staff support people more effectively. However, they had not ensured staff were skilled in relation to supporting people with behaviours of concern, such as with de-escalation techniques. Feedback received raised concerns that not all staff appeared to have the necessary skills to meet a person’s needs. The registered manager advised they were sourcing further training, with input from an external consultant.

Staff told us they were offered supervision meetings with managers. We saw records in relation to these being carried out, including competency checks. However, we found inconsistencies in records relating to the dates of supervision meetings.

Overall, people were supported by a familiar staff team, and new staff had been recruited where required. Managers had been liaising with the local authority in relation to ensuring sufficient staffing hours were in place to support people safely.

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.

The provider had an Infection prevention and control (IPC) policy. Staff undertook training in relation to IPC. They had access to suitable PPE, and we saw the living environment was clean. Managers undertook audits to ensure procedures were followed.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider had a medication policy in place. Staff undertook training and managers assessed their competency to administer medicines safely. However, the provider had not ensured staff robustly followed procedures. Where a person was prescribed ‘when required’ (PRN) medicines, staff did not have clear guidance to know when to administer these. Staff had completed a medication risk assessment for the covert administration of medicines (hidden in food and drink), which had been agreed in the person’s best interests. However, there was no specific care plan in place in relation to the safe administration of these.