PI Care, a domiciliary care agency supporting children and young adults with learning disabilities and autism, improved its Safe rating to Good following remediation of breaches in medicines management, recruitment, and safeguarding processes. Well-Led remains Requires Improvement due to the recent appointment of an unregistered manager, governance improvements not yet sufficiently embedded, and an inadequately handled safeguarding investigation.
Concerns (6)
criticalSafeguarding: “An allegation was made about physical abuse of a person by a member of staff. Other professionals asked the provider to investigate the allegation, but they were not confident in the initial investigation.”
moderateGovernance: “Due to the relatively short time frame since the last inspection, we were unable to evidence the improvements were truly embedded and systems of governance were consistently robust, reflective and transparent.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post. A new manager had been in post for around 6 weeks and planned to apply to register with CQC.”
moderateIncident learning: “The provider had not always been proactive in identifying potential concerns and taking appropriate actions to improve or mitigate risk.”
moderateStaff competency: “Two professionals felt staff knowledge and training were insufficient. One said they had, 'grave concerns' about the service.”
minorCommunication with families: “Comments included, 'The management and their communication is really awful'... 'communication had been variable'.”
Strengths
· Medicines management improved since last inspection; MAR records complete with dose, method, timings, allergies, and preferences.
· Recruitment processes strengthened with DBS checks, references, and recruitment audits now in place.
· Staff demonstrated clear understanding of individuals' needs, risks, and communication methods.
· Provider no longer in breach of Regulations 12, 17, 18, or 19 following improvements since last inspection.
· Post-incident reviews conducted after restrictive practice to identify future risk reduction.
PI Care, a small domiciliary care agency in Bradley Stoke, received an overall rating of Requires Improvement at its first inspection in September 2022, with regulatory breaches identified in medicines management, staff recruitment checks, governance, and CQC notifications. Care delivered to the one person receiving regulated personal care was person-centred and effective, supported by a consistent multidisciplinary team, but systemic governance and oversight failures posed risks as the service sought to grow.
Concerns (7)
criticalMedication management: “People could not be assured their medicines were managed safely. This had not been recorded on the electronic medicines record (MAR)... One of the medicines on the MAR did not include the dose.”
criticalStaff training: “Not all documentation was in place prior to a member of staff starting work, such as a Disclosure and Barring checks (DBS).”
criticalGovernance: “There were no formal audits of the systems enabling the provider to monitor the service such as care plans, medicines, recruitment of staff and service delivery audits.”
criticalIncident learning: “The provider had failed to notify us of two incidents that were reportable to the Care Quality Commission... an incident where the police were involved and the other related to the loss of staff recruitment and training records.”
moderateRecord keeping: “The provider told us they had lots of contact with the staff and a team meeting, but this had not been recorded.”
moderateLeadership: “Since May 2022 there had not been a registered manager... the senior management team had not visited the person receiving the service to ensure ongoing compliance since July 2022.”
minorComplaints handling: “When we discussed some concerns raised by the person's relative about meal choices... This had not been logged as a complaint or a concern in relation to the care of the person.”
Strengths
· Sufficient and consistent staffing team in place for the person receiving personal care, with contingency plans for continuity
· Staff received training in safeguarding, positive behaviour support, lone working, equality and diversity, and communication including Makaton
· Weekly multi-disciplinary meetings with health and social care professionals ensured ongoing review of care and risk management
· Person-centred care planning involving the individual, their relative and external professionals, with personalised activities and choice
· Clinical lead nurse recruited in response to relative and commissioner feedback, improving care consistency and outcomes
Quality-Statement breakdown (22)
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on the duty of candourRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Engaging and involving people using the service, the public and staffGood