Archived: MediPatrol Ltd

We inspected safe and well led domains for MediPatrol Ltd. but did not rate them at this inspection. We are taking regulatory action in response to the concerns we have described and this is ongoing at the time of publication.

• There were no reliable systems to ensure staff were trained adequately for their roles to keep patients safe. There was no assurance that staff had training in key skills, understood how to protect patients from abuse or manage safety well. The service did not always control infection risks well. Staff assessed risks to patients, but the provider was not able to assure us that staff were adequately trained to be able to safely monitor patient conditions. There were no records kept by the service of patient monitoring or their conditions. Medicines were not securely and safely stored nor were expiry dates checked and acted upon. There was no embedded system for staff to identify, report, receive feedback or share learning about incidents and concerns. Safety was not a sufficient priority. Managers did not ensure actions from patient safety alerts were known, implemented and monitored.

• Leaders of the service showed a limited understanding of the safety and business priorities and how to manage them well. There had been major disagreements between directors, which caused a disconnected and dysfunctional leadership team. There were no reliable and consistent systems which provided oversight of safety and quality of care delivered. Systems that were in place had been stopped and not all staff and leaders had access to them. This had led to disruption for the maintenance of electronic records. Leaders were not clear about their legal limitations of providing care and what regulated activities they should be registered with the Care Quality Commission (CQC) to provide. Leaders tried to support staff but found it challenging and opportunities for staff development were limited. Staff were allocated roles but not always provided with opportunities to access specific training to support these roles. Leaders and staff wanted to provide a safe service and wanted to put the patient at the centre of their service planning. However, they were not clear on how they would achieve this. There was no consistent, embedded system for gathering and reviewing feedback, incident reports or risks. This had the impact of limiting opportunities for learning and improvement. There were processes for gathering patient views but there was no documentation of how these were discussed or actioned. Staff support systems were inconsistent and guidance for staff depended upon who they contacted within the senior leadership team.