Passion Home Care 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Accidents and incidents had been managed effectively. A log had been used to document each one, which explained what had happened, actions taken and outcomes, along with any lessons learned. Learning had been shared with all care staff to help drive improvements. Staff told us how the process worked. One stated, “All incidents, accidents, or near misses are recorded using the incident form and body maps on our [electronic system]. I include a clear description of what happened, and immediate action taken. Escalating the incident to management is a priority, and I report this through the office team or the on-call staff.” Another said, “We receive weekly newsletters and incident learning reports, which help us learn from any incidents and improve our practice as a team.”

An up to date complaints policy was in place and complaints received, of which there were few, had been managed in line with this. Records explained the nature of the complaint, action taken and outcomes. Where any shortfalls in practice had been identified, learning had been recorded. As part of their complaint process, the provider contacted people separately to check they were happy with actions taken and satisfied with any outcomes. The provider had also apologised for any errors or mistakes, in line with their duty of candour policy.

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.

Handover documents had been completed when people transitioned to other services, such as a new care provider. These explained people’s needs and preferences, including any personal goals and how they liked to be cared for and supported. This helped ensure continuity of care and promoted people’s safety.

The provider was flexible and proactive when admitting people to the service. For example, accepting requests from the local authority to admit people earlier than planned, to ensure people’s safety and prevent any shortfall in care provision.

Care staff understood the importance of ensuring they knew people’s needs prior to providing support. One staff member told us, “I believe effective communication is the key to providing safe, high-quality, person-centred care. When I start supporting a new service user, I always read their care plan, medication information, and risk assessments to understand their health conditions, support needs, and any potential risks. My coordinator and office staff also provide a detailed handover following the initial assessment, which helps me understand the person's health needs, mobility, daily routine, preferences, and any specific wishes they have.”

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. The provider shared concerns quickly and appropriately.

People were safe and protected from harm. Staff had received training in safeguarding, knew the different types of abuse, how to identify these and how to escalate concerns. One staff member told us, “I have completed mandatory safeguarding training. I understand that safeguarding is an essential part of my job, and my role is to protect service users from abuse, neglect, and harm by recognising concerns and reporting them promptly through the correct procedures.”

Safeguarding concerns had been reported to the relevant local authority in line with guidance. A log had been used to document any referrals, actions taken and outcomes. As with accidents and incidents, the provider had taken any learning from each safeguarding concern and shared this with the wider staff team.

Professionals working with the service also spoke positively about their management of safeguarding issues. One professional stated, “When concerns or safeguarding matters arise, they are reported appropriately and managed openly and transparently with relevant professionals. Through safeguarding reviews, I have seen clear evidence of root cause analysis, lessons learned, and the implementation of preventative measures to minimise the risk of recurrence.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A range of assessments had been completed to assess risks to people and how to mitigate these. As much as possible, people had been involved in this risk assessment process.

Documentation was detailed and provided clear guidance for staff to follow. One staff member stated, “Care plans and risk assessments give me clear and sufficient guidance to manage risk safely. The care plan tells me what care and support the service user needs and how they would like that care to be provided. The risk assessment tells me what risks have been identified and how to manage them safely. If I notice any changes or new risks, I report them immediately so the risk assessment can be reviewed and updated.”

We looked at how this process worked in practice. One person had initially been assessed as needing support from 1 carer, as they could stand and transfer with minimal assistance using a walking frame. Over time, care staff noted the person’s mobility was deteriorating, they became unsteady on their feet and at greater risk of falls. These issues were reported to management. A care review had been completed, risk assessments updated and staffing levels increased from 1 staff per visit to 2, to ensure staff could safely assist with transfers and personal care.

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

Environmental risk assessments had been completed to ensure both staff and people remained safe. These covered a range of areas including slip and trip hazards, presence of pets, fire safety and access to the property. The assessment was revisited twice yearly during care reviews with each person, to ensure it remained relevant.

Specific risk assessments had been completed, where people used equipment such as hoists, wheelchairs, commodes or stand aids. These were detailed documents, which included guidance for use and how to ensure the equipment was safe. Although they were not responsible for any equipment, the provider kept a list of when people’s equipment required servicing, who completed this task and their contact number. This enabled them to ensure equipment was safe to use and support people to arrange for servicing and repairs, if and when required.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Overall, people and relatives spoke positively about the timeliness of care visits. Staff were largely punctual and stayed for the planned duration of each visit. One person stated, “I have a morning, teatime and nighttime call every day, time keeping is good. Sometimes they can run late if they have been delayed at their last call, but I don’t worry as they always turn up and have never let me down.”

The provider used an electronic system to plan care visits and generate staff rotas. Staff were happy with how the process worked. One staff member told us, “My rotas are generally well organised and planned in advance, which allows me to manage my time effectively. I have enough time to complete all tasks, talk to the client, and keep accurate records.”

Staff had been recruited safely, with all necessary employment checks carried out and documented. Each staff member had completed a detailed induction, which included training in key topics and time shadowing experience staff. A staff member stated, “My induction

helped me to understand my role and responsibilities and the organisations policies and procedures. I did training in safeguarding, infection prevention and control, moving and handling, person centred care and also how to report concerns. This helped me carry out my duties with confidence.”

Ongoing training was provided and monitored via the provider’s electronic system. This showed all staff were up to date with any assigned training courses. Spot checks and competency assessments had also been completed, to assess staff practice and ensure they were providing safe and effective care.

Further support was provided through completion of supervision and appraisal meetings, where staff had the opportunity to discuss their work, raise any concerns, receive feedback on performance, and identify any training or support needs.

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.

Staff had received training in infection prevention and control (IPC) and the safe and correct use of personal protective equipment (PPE). This included attending a webinar run by the local authority.

PPE was readily available in both the office and people’s homes and used as required. The provider completed spot checks to ensure staff were adhering to IPC guidance, including hand washing guidance and wearing PPE appropriately.

Where people’s care included domestic tasks such as cleaning and laundry, information was in place for staff to follow, to ensure this was done safely and infection risks managed. This included, prompts for staff to check expiry dates and remove any old or out of date foods.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received safe and effective support with their medicines. People told us they were happy with the support received. Comments included, “I always get my medication and have no concerns” and “Care staff support with my medication. They sit next to me to make sure I have taken it all, they always check that it has all gone.”

Medication records had been completed accurately and consistently, with formal checks and audits in place to monitor this. Guidance was in place for staff to follow, to ensure they knew what medication to give, when and what for. This included as required medicines, such as pain relief.

Care staff had received training in medicines management and had their competency to administer medicines safely checked. One member of staff told us, “I have received medication training, and my competency has been assessed and checked. This ensures that I follow the correct procedures and administer medicine safely and confidently.” Another stated, “Before administering any medication, I always read the care plan and carefully check the Medicines Administration Record (MAR) to make sure I am giving the correct medication, to the right person, at the right time, in the correct dose and by the correct route.”