Archived: Priory Alliance Care 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

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 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, safe staffing and person centred care.

This service scored 28 (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 transparency. Lessons were not learnt to continually identify and embed good practice.

Systems that support learning, such as audits, reviews of incidents, or structured team communication, were not in place. This meant risks were repeated and emerging concerns were not identified early. Leaders were not aware of their responsibilities for investigating concerns and ensuring safe practice.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

There were no systems in place to make sure safe care was provided. Care plans lacked essential detail, including instructions for mobility, diabetes management and skin care. One staff member said, “I wouldn’t read the support plan as it wasn’t what I liked to do,” and others confirmed they relied on the manager or family for guidance. Call monitoring was not in place. Staff usually left visits earlier than they should have done which placed people at risk of harm and their care needs not being met.

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 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 share concerns quickly and appropriately.

Safeguarding arrangements were not robust. While some people told us they felt safe with staff. We spoke with staff around their knowledge of safeguarding and how they would respond if they had concerns about a person. Staff told us they would report concerns to the registered manager but did not demonstrate an understanding of where to escalate their concerns to external agencies if needed. A staff member said, “I would call [branch manager] or whoever is in the office if I had a concern.”

The registered manager told us, “No safeguarding’s have been reported.” However, during the inspection we identified safeguarding concerns relating to unmet care needs that had not been recognised or reported by the registered manager. The provider had reduced a person’s commissioned care calls. This decision was made without completing appropriate checks to ensure the person could afford their future care and without considering the person’s assessed needs. Despite this, the provider did not raise a safeguarding concern or a statutory notification to the Care Quality Commission (CQC). There were no clear escalation routes, decision‑making records, or documented actions to protect people from harm. This lack of oversight and failure to escalate placed the person at risk of abuse or neglect.

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. People were not involved in managing their risks. Care plans were generic and task-led, with no personalised instructions. Staff said they would “ask the clients or the manager” rather than follow documented plans. There was no evidence of discussions with people or families about risk management. This failure increased the likelihood of unsafe care and avoidable harm being caused.

There was no detail or guidance to staff about how to support people with their conditions. The risk assessment listed potential risks, however, where risks had been identified, they had not been explored and managed. For example, where a person identified at risk of skin damage, they had no care plan for staff to follow for repositioning which placed the person at increased risk of pressure damage.

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

Environmental safety checks were inconsistent and undocumented. The registered manager described checks verbally, such as “Make sure equipment is safe… carpet not thick,” and records were generic and lacked detail of potential hazards and risks. Equipment servicing dates were not included in people’s care plans, and some pieces of equipment were not identified at all within the care plan documentation. This meant staff did not have the information they needed to verify whether equipment was safe, serviced, or appropriate for use, increasing the risk of unsafe care. For people who required support with their mobility, documentation contained conflicting and contradictory instructions on how staff should provide safe assistance. Staff told us they often relied on direction from the person’s next of kin, which is not an appropriate or safe practice and indicates a lack of professional guidance, assessment, and oversight. These failures meant people were at increased risk of harm due to ineffective safety checks, poor record‑keeping, and unclear moving and handling guidance.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not 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.

Staff were not always recruited safely. One staff member provided care for people but essential checks, such as reference being sought and explanations for employment gaps, were not checked. Training oversight was poor; the manager said, “It’s just jotted down,” and the training matrix was implemented only prompted during assessment. Staff with no previous care experience were not given additional support. Staff lacked basic knowledge of care, and some staff could not explain basic safety concepts, such as diabetes risks. As call monitoring was ineffective, leaders could not be assured staffing levels and deployment of staff were sufficient particularly for people who needed two staff members or those people cared for in bed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection control measures were weak. The registered manager did not check staff were wearing personal protective equipment (PPE). The provider relied on verbal assurances rather than systematic monitoring. This failure increased the risk of infection transmission. However, staff said they were aware of how and when to wear PPE and PPE was available for staff to collect from the branch office.

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.Medicines were not managed safely. There were no medication care plans, and topical creams were applied without clear guidance. People did not always have documentation in place for the administration of creams and where they were in place, the document lacked detail. Staff did not follow the provider’s policy on safe medication administration. One staff member said, “We pass blister packs to clients and help give medications.” However, the providers medicines policy required staff to document consent and risk assessment for all people receiving medication support. This was not in place. We found the same staff member’s signature appeared three times per day over 28 days, raising concerns about accuracy of the record keeping. This lack of oversight placed people at risk of harm from incorrect or inconsistent medication support.