Pure Moments Ltd

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 management of medicine and staff recruitment.

This service scored 53 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and were aware of process to report safety events. There was a system in place for recording accidents and incidents. There had been some incidents and concerns recorded and investigated. However, we noted to the nominated individual that it was not always clearly recorded what action was taken or the outcome. For example, for one person, it recorded they had pressure damage and a scratch, but it was not clear when these appeared, and what the final outcome was. We spoke about analysis of incidents and accidents to identify any themes or trends. The nominated individual said they had reviewed and discussed one incident with staff and how they could learn from it. However, this was not done for other incidents recorded. This area required further development to ensure all staff were actively involved in the process, enabling meaningful learning and the effective measurement of outcomes and service impact. Staff said they would report any incidents or issues to the registered manager, record in the daily notes, inform the family (where appropriate) and take any necessary action should some require medical attention. Staff also noted they would contact emergency services or other health professionals for medical advice. However, staff said they would take advice from the registered manager first. Staff were reminded to ensure they called the emergency services before contacting the office should they find someone unconscious or unresponsive when first arriving at a visit.

We discussed duty of candour with the registered manager and the nominated individual, including which incidents are required to be reported to the Care Quality Commission (CQC). The provider had a policy for actions that staff should take in situations where the duty of candour would apply. The duty of candour is a legal and professional requirement for health and social care providers in the UK to be open, honest, and transparent with people (or their families) when something goes wrong with their care or treatment, causing, or having the potential to cause, significant harm. There had been no notifiable safety incidents where duty of candour would apply.

The provider worked with people, their relatives 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 and if people would need to move between different services. People and relatives were involved in the planning and reviewing of their care and informed and supported by the registered manager and the staff team. The registered manager told us how they worked together with people, families and professionals where needed. Having all the information from different parties helped the provider get to know people and establish individual plans of care for them.

The provider understood what being safe meant to people and the best way to achieve that when supporting them. However, we found 2 incidents where safeguarding alerts were not raised to external agencies for further investigation. The provider had investigated the incidents internally. We discussed this matter with the registered manager and the nominated individual to ensure such incidents were reported properly to ensure people were not at risk of ongoing harm or abuse.Staff worked together and kept people safe from avoidable harm because they knew them well and understood how to protect them from abuse. People felt safe when receiving care from the staff. The relatives agreed people were safe when receiving care and liked the staff who supported them. They said, “We all feel safe when the staff are here and there have never been any issues or concerns or worries” and “As the live in carer is here 24/7, [the staff] is now really like a family member…[the staff] is trusted.”Staff were aware of how to recognise abuse and protect people from the risk of abuse. Staff knew how to report concerns including external agencies. They were confident the registered manager and the provider would act on any concerns reported to ensure people's safety. Staff said they were approachable and felt confident in raising concerns or asking for advice.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. At the time of assessment, no one was deprived of their liberty or had any restrictions placed on them.

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 had care plans and risk assessments describing support and care needed. However, some information regarding how the risks were managed needed further review to ensure the right care and mitigation was provided consistently according to plans of care. For example, one person was at risk of issues with their skin integrity. They had a body map which included areas to monitor but there was no clear risk assessment for any further mitigation to be considered and ensure the risk of pressure damage was reduced. Another person had issues with weight loss and nutritional intake, but the care records did not fully reflect that. The person was at high risk of choking according to speech and language therapist (SALT) review however there were no further clear guidance how SALT information was used to establish further risk management. We spoke to both the registered manager and the nominated individual about ensuring clarify in people’s records for specific areas of risk management and oversight.Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them. The registered manager and staff assessed and reviewed the risks to people’s personal safety and put plans in place to minimise these risks. The service had business continuity plans in place to ensure the service could continue in the event of an emergency. The staff told us they were able to contact the managers for any help and advice at any time.

The provider detected and controlled potential risks in the care environment. They made sure any equipment, facilities and technology supported the delivery of safe care. The service supported people and relatives to oversee and manage potential risks in the home environment. The provider reviewed any risks and mitigation. As part of the assessment, the service carried out a health and safety assessment of the environment to review any risks and ensure people, their family and staff were safe while carrying on the regulated activity. Staff noted if they were worried about people, they would report this to the registered manager and family to ensure timely response. The staff and the provider supported and protected people safely without any restrictions or use of restraint.

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. We found gaps and discrepancies with recruitment records such as gaps in employment; seeking evidence of conduct and verifying reasons for leaving; and 1 health and fitness check was missing. We discussed these issues and requirements of the regulation with the nominated individual. After the site visit, they provided some of the information however it demonstrated the process needed further improvement. The provider needed to improve completion of some of the training topics. Some people needed support with catheter care, skin integrity, monitoring of nutrition and hydration but training was not provided for these care tasks. Not all staff had up-to-date medicine management training and were supporting with medicines. Staff assessing competencies in medicine and moving and handling, did not have training to complete such assessments for staff. Having staff supporting people without fully up-to-date knowledge and skills, could put people at risk of harm or injury. We considered this under the well-led key question.

People and relatives told us they were happy with staff and the way they supported people. People and relatives said staff skills were checked by the nominated individual. Staff also went through induction and shadowing period before working independently. The provider, the registered manager and staff worked together well to provide safe care that met people’s individual needs. People and relatives confirmed they had regular staff coming to support them and completed all the care and support needed. They were complimentary of staff’s support. They said, “My [relative] benefits from continuity of staff” and “New staff shadow [the nominated individual] before they attend on their own, so I know the skills are in place. ”Staff confirmed there was enough time to complete the tasks on the visits. The registered manager and the nominated individual also supported people with their care and covered staff absences to ensure support was not compromised. This was appreciated by people, relatives and staff. They said staff arrived as near to the time as possible. If there were any delays, the nominated individual would inform people and relatives. They said if staff arrived early, they stayed the full time taking a chance to chat for a while with people. Staff felt they received training that equipped them with the knowledge they needed to support people. Staff said they all went through the same process regardless of previous experience to ensure consistency in provider’s expectations of care provision.

The service assessed and managed the risk of infection. All staff said they had access to personal protective equipment and used it to prevent the spread of infection. They said they collected supplies from the office, and these were never restricted. Staff understood the importance of infection control. Any issues or infections would be reported to the registered manager to ensure a timely response and support to people. Staff received training in infection control and followed the provider's policies and procedures on this. People and relatives confirmed staff wore the protective personal equipment while supporting them.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. The provider needed to make some improvements to the management of medicines.Only some people were supported by staff to manage their medicines. However, the completion of medicines management records needed reviewing and improving according to the provider's policy and current best practice guidance. For example, we looked at one person’s medicines administration record (MAR) charts and daily notes. The nominated individual said this person was not supported by staff to have medicine. However, from daily notes, it was recorded staff gave the person medicine such as indigestion remedy and multivitamins. It was not on their prescribed medicine list.Another person had prescribed topical medicine to support skin integrity however this was not included on the MAR chart to ensure there was a clear record this task was completed. A third person was supported by staff to apply a topical medicine as a homely remedy. This is medicine is purchased over the counter rather being prescribed. There was no record of a MAR chart in place for this. Some people received their medicine in the afternoon when the prescription noted it was morning medicine. MAR charts were not always signed to indicate the medicine was given. The provider had policies in place stating how to manage medicine safely, but these findings did not always reflect staff were following it accordingly.