PAI Healthcare Ltd achieved an overall Good rating on its first inspection, with staff delivering safe, caring and person-centred support to 15 people in their homes. However, the Well-Led domain was rated Requires Improvement due to insufficiently detailed care records, undocumented governance audits, and failure to notify CQC of two safeguarding incidents and an office address change.
Concerns (6)
critical
Governance
: “two safeguarding incidents had been reported to the local authority but not reported to CQC as required.”
moderateRecord keeping: “care records lacked sufficient details, and we found two examples where a risk assessment and care plan had not been developed for an identified health need.”
moderateGovernance: “Audits around the quality of care or staff competency were not formally documented or recorded to inform service improvement.”
moderateCare planning: “People's care plans lacked sufficient detail to guide staff.”
moderateIncident learning: “monitoring systems did not look for trends, patterns or causes.”
minorStaff competency: “Although staff told us competency checks had been carried out, we could not see that these had been formally recorded.”
Strengths
· People received care from a consistent staff team enabling continuity and timely visits with no missed calls reported.
· Staff had received safeguarding training and knew how to escalate concerns to the local authority or CQC.
· Effective infection control processes were in place including regular COVID-19 testing and appropriate PPE use.
· People received their medicines as prescribed by a staff team trained and competency-checked in medication administration.
· People and relatives were fully involved in care planning decisions and spoke positively about the kind, caring attitude of staff.
Quality-Statement breakdown (19)
safe: Systems and processes to safeguard people from the risk of abuse; Learning lessons when things go wrongGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
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; staff working with other agencies; supporting people to live healthier livesGood
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: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, understanding quality performance, risks and regulatory requirements; duty of candourRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Continuous learning and improving care; working in partnership with othersGood