Archived: Priory Alliance Care Limited

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the provider met people’s needs.

This is the first assessment for this newly registered service.

This key question has been rated inadequate.

This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation person centred care.

This service scored 25 (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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Although people and relatives described receiving person‑centred care in practice, this was due to staff knowing them well rather than because care was planned or reviewed in a structured or reliable way. People told us staff were kind and supported them in a way that felt individual to them. However, these positive experiences were not supported by care records. Care plans did not set out people’s preferences, routines or what mattered to them, and information was repetitive and generic across all three plans. Important details about people’s medical conditions, risks and changing needs were missing, inconsistent or incorrect, meaning staff did not have the information they needed to provide truly person‑centred support. The lack of personalised guidance meant staff relied on verbal information from relatives, other carers or the manager, rather than a clear and up to date plan, which placed people at risk of receiving care that did not meet their individual needs.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

The provider could not demonstrate staff stayed for the full length of time or that two staff consistently attended two person calls. The registered manager told us they relied on what staff recorded and on a basic daily log sheet, but these checks only confirmed whether a time arrived and time leaving the property, not whether care was delivered safely, whether times were accurate or whether outcomes were met. There was no structured oversight, which meant leaders could not be assured that people received the level of care they required.

Care was not well coordinated with commissioners or external agencies. In one case, the provider reduced a person’s commissioned care calls based on finances, and before any local authority assessment had taken place to assess the person. This decision was made without a documented reassessment, updated care plan or multidisciplinary involvement, despite the person being at high risk of harm without the full commissioned support.

Some people living with dementia received support from staff who had completed training, but care plans did not describe how dementia affected people individually or what personalised communication or support approaches should be used. While the small size of the service meant people experienced continuity through the same staff attending regularly, this familiarity did not mitigate the absence of personalised dementia‑specific guidance. There was a lack of structured oversight needed to ensure people’s needs were consistently and safely met.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Across all people, key documents were incomplete or absent. There were limited consent forms in care files, and mental capacity assessments were generic, with “yes/no” responses and no detail about how mental capacity had been assessed or who was involved in decision making documented. This meant people and families could not see how decisions about care and contracts had been made or how their views were considered.

For one person, there were serious discrepancies in contractual information. The local authority confirmed that commissioned support had been explored for one person. It included an electronically applied signature that did not resemble the person’s usual signature, and the representatives told us they were not aware a private contract had been signed.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

The registered manager told us care plans would only be formally reviewed annually, and “reviews” were informal phone calls that were not recorded in people’s files. This meant changes in people’s needs, preferences or financial circumstances were not captured in updated assessments or shared with the wider staff team. For example, one person’s medicated creams prescription had been changed but this had not been updated in the care plan and daily logs did not record the application for this medication.

While some people and relatives gave positive feedback about individual care workers, the overall governance and documentation did not show a culture of listening, responding and co‑producing care. People’s views were often overshadowed by informal arrangements and undocumented decisions, which left them without a clear record of what had been agreed and how the provider would act on their feedback.

One relative we spoke with that gave highly positive feedback about documentation and contract information was later identified as an impostor. They were not the legitimate next of kin for the person concerned, and the registered manager was aware of, this raised concerns about the accuracy of information provided to the assessment team.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it. Decisions about access to care were sometimes driven by finances rather than an objective assessment of need. without a documented needs reassessment.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

There was no structured process to monitor outcomes or compare experiences across different groups of people using the service. Audit activity was limited to checking daily notes were present, without examining the quality of care described or whether people’s goals and health outcomes were being achieved. As a result, patterns such as shorter call durations, missing records and lack of detail about health risks were not identified or addressed, even for those with higher risk profiles.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The registered manager told us formal reviews would be carried out annually, and there was no evidence of structured interim reviews, even where there were clear changes in people’s health.

We saw no evidence of proactive planning with people around deterioration in health, changes in mobility, or preferences for end of life. Instead, decisions were reactive and often undocumented. This meant people were not supported to make informed decisions about their future and there was a risk that care would become increasingly unsafe or unsuitable as their needs changed.