Pride Home Care remained Requires Improvement at this focused inspection, with a repeated breach of Regulation 17 due to ineffective medicines audits that failed to identify gaps in MAR records and unsafe transdermal patch recording. Safeguarding, infection control and staff deployment systems were working well, but governance oversight of medicines and consistency of call timings still placed people at risk of harm.
Concerns (7)
criticalMedication management: “Medicines oversight was not robust. We identified examples where the electronic medicines administration record (MAR) had not been completed.”
criticalMedication management: “Documentation did not demonstrate that medicated patches were applied in line with manufacture's guidance. Staff were not recording the location of the application or removal of the transdermal patch.”
criticalGovernance: “Systems were not robust enough to demonstrate medicines were effectively managed. This placed people at risk of harm. This was a repeated breach of regulation 17 (Good Governance).”
moderateRecord keeping: “Care plans required greater detail where people would sometimes self-administer their own medicines, or when people refused their medicines.”
moderateMissed or late visits: “Not all people were clear on who would be supporting them and when. A person told us, 'The time varies (of the calls), we used to get a rota but we don't now'.”
moderateStaff competency: “inspection findings identified the need for a greater focus on the recording processes relating to supporting people with their medicines.”
minorRecord keeping: “a risk assessment was missing on the day of the inspection relating to a staff member, in addition to reasons for some staff leaving previous roles was not detailed.”
Strengths
· Registered manager took immediate action to strengthen medicines recording when issues were raised
· Staff completed safeguarding training and were confident on how to report concerns
· Staff felt staffing levels had improved and there were always enough staff to support people safely
· Electronic system used to monitor deployment of staff and alert to late calls
· Care plans and risk assessments accessible to staff via mobile devices with current information
Quality-Statement breakdown (10)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentRequires 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
well-led: Promoting a positive culture / continuous learning / managers and staff clear about roles and risksRequires improvement
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated
well-led: Duty of candour and openness when things go wrongNot rated