Primary Care Recruitment 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 a legal regulation relating to governance and oversight. Governance systems had not identified the issues found during our assessment, including concerns about the accuracy and completeness of records used to support the safe management of medicines.

This service scored 62 (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 investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider demonstrated a willingness to learn when things went wrong and used information from incidents and concerns to improve people's safety and support. Staff and managers reviewed incidents to understand what had happened and identify whether any changes were needed to reduce the likelihood of similar incidents occurring again. Complaints and concerns were investigated appropriately and the provider responded to issues raised.

Behavioural summaries for people showed fewer serious incidents and less use of restrictive interventions by staff. This showed the provider had taken steps to better understand people's needs and put in place support strategies that helped achieve better outcomes.

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.

The provider worked well with other professionals to help keep people safe and meet their needs. Staff followed advice from health and social care professionals and used it to guide the support people received.

Care records showed professional recommendations were put into practice. When a person's needs changed, the provider sought further assessments to make sure they continued to receive the right support and that risks were managed effectively.

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.

Staff were able to explain how they would report potential safeguarding concerns and escalate them to the appropriate people when necessary. This helped to ensure concerns could be acted upon promptly to protect people from harm.

The provider had safeguarding policies in place for both adults and children. These gave staff guidance on their responsibilities and the steps they should follow if they had concerns about a person's safety or wellbeing.

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.

We found risk assessments relating to medicines, were not always in place. This was discussed with the registered manager, who took action to address the concerns. Whilst this showed there were gaps in some areas of risk management, there was evidence that the provider considered risks in other aspects of people's support.

People were supported to take part in activities and daily routines whilst managing risks appropriately. Risk assessments were in place for a range of activities and provided guidance for staff on how to support people safely. These assessments helped people to make choices, try new experiences while reducing the risk of harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider took steps to ensure the environments remained safe. Staff carried out checks on manual handling equipment before it was used to make sure it was safe and in good working order. This helped to reduce the risk of injury to people and staff during transfers and moving and handling tasks.

The provider regularly monitored the environment and responded quickly when risks were identified. Issues were reported and acted upon in a timely way to reduce potential risks to people's safety and wellbeing. Where improvements or repairs were needed, appropriate action was taken to address these concerns.

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 could not demonstrate that all staff had completed the training required to support people safely and effectively or for their individual roles. Training records were not always clear, accurate or up to date, which made it difficult to confirm which training staff had completed and whether refresher training had been undertaken when required. As a result, the provider could not consistently demonstrate that all staff had the necessary skills and knowledge to carry out their roles.

Despite this, staff received regular supervisions. The provider also completed competency checks for some tasks to help ensure staff were carrying out these responsibilities safely and in line with expected standards.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Cleaning checks were completed where appropriate to help maintain a clean and hygienic environment. These checks supported infection prevention and control measures and helped to ensure people's living spaces were kept safe and comfortable.

The provider did not always ensure medicines were managed safely. There were occasions where people were not involved in planning about medication-related risks.

Medicines were not always managed safely because records did not always contain clear and consistent information for staff. We found differences between care plans and medication records, including information about medicines, doses and how often medicines should be given.

Medication records were not always completed fully. Some records were missing important information, such as the exact time medicines were given, administration codes, or details of medication stock received. Although the provider carried out medicine’s audits, these had not identified the issues found during the assessment.

There were also gaps in how some risks relating to medicines were managed.

However, records demonstrated that STOMP (Stopping Over Medication of People with a Learning Disability, Autism or Both) principles were being followed, with medicines used appropriately and not relied upon as the primary way of calming people.