Prudent Domiciliary Care Limited (PBG)

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

We found breaches of the legal regulations in staffing, safeguarding and safe care and treatment. People did not always receive care as planned. There were significant and multiple delays in care visits, visits shorter than planned and staff rosters were not always planned to provide staff with travel time and breaks when working long days. This negatively affected people’s experience of care and the quality of their lives and put them at risk of avoidable harm. People told us the lateness affected their day to day lives and sometimes meant staff did not have an opportunity to check on people and to provide their care when it was most needed. For example, when people were alone for extended periods of time, required personal care, or when they needed help to prepare a meal to take their medicines on time. There was limited assurance on how the provider recognised and monitored which visits were missed, and how the provider safeguarded people from the risk of avoidable harm and neglect. The provider had systems and processes for safe management of medicines and IPC. However, these were not followed consistently which put people at risk of harm and not receiving their care as required. The provider was aware of these issues but did not recognise the full severity and impact they had on people’s care. Some improvement actions were underway, but these were not effective to mitigate the risks to people and ensure their experiences of care was not negatively impacted. People and their relatives told us they did not always feel listened to and confident their concerns would be consistently addressed by the provider and actioned to make improvements when things went wrong.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always happy with how the service learnt lessons when things went wrong. Some people told us their concerns were not responded to at all, some were not happy with how the service responded and they told us lessons were not learnt to improve. For example, one relative told us they had raised verbal complaints about the delays in care calls in the past and nothing was improved, nor did they receive a response from the service about what actions would be taken. Multiple people and their representatives told us they changed their care arrangements due to the provider not addressing their concerns effectively.

The registered manager told us they analysed and reviewed incident and accident reports using their electronic care planning system. They explained they implemented additional training for staff and improved their recording systems because of lessons learnt identified from incidents and safeguarding concerns. However, lessons were not always identified and learnt when people told us they raised concerns or where people’s care records showed their care was delayed.

Although there were systems in place to record and review incidents and accidents, these were not wholly effective and did not always ensure people’s safety. The provider had an accident and incident policy explaining the registered manager was responsible for reporting any accidents and incidents externally, carrying out an investigation and implementing any recommendations and lessons learnt from the outcomes of these investigations. People’s records included evidence of actions taken following incidents reported by staff. However, opportunities to learn lessons from people’s feedback and safeguarding concerns were missed as not all investigations were carried out thoroughly and not all feedback was fully analysed to identify lessons learnt.

The service did not always ensure the continuity of people’s care was maintained. People told us they felt involved in initial planning of their care. However, people also commented that not all transitions in care were managed well by the service. Some people told us their care visits were not planned correctly and they had to arrange alternative care before the service was ready to support them after hospital stay on their return home. One person said, “I went to hospital the other day and rang to say I had gone in, and they said to ring them when I leave, and they would put evening call in, but they didn’t arrive. I spoke to [the registered manager]. They said they put it on the system and don’t know what happened. I slept in the clothes I had been in all day and the night before.”

Staff told us they were provided with information around people’s changing needs and before they started supporting new people. Staff had access to the electronic care planning system and were updated by the management about any changes which affected people’s support. The care coordinator told us senior staff would complete an initial care needs assessment and work in partnership with people and other healthcare and social care partners to inform individual care plans. They also commented, “I make a care plan off of what [partners] say [the person’s needs are] and then edit it as I speak with people.” However, this was not always effective as people’s experiences varied and multiple people were affected by delays in care or their wishes around continuity and care provision not being appropriately considered and actioned by the provider.

Partners told us they were supporting people to manage complaints and to address and investigate any concerns that were raised prior to and during the assessment.

The provider had systems and processes in place to assess people’s needs before agreeing to support them, but these were not always effective. Senior care staff and management were completing initial needs assessments and coordinating any transitions in people’s care. They created people’s care plans and sought consent from people to obtain information from healthcare services they used to inform their care. However, the roster planning issues negatively affected how people’s care was planned and delivered and their experience of transitions in care.

While people we spoke with expressed they felt safe, our assessment found care did not meet the expected standards. People and their relatives told us they felt people were safe with staff, but the delays and inconsistencies in provision of care visits meant they were not always receiving their care as required. This put them at risk of neglect and avoidable harm due to missing meals, medicines or delays in personal care.

The registered manager could explain how they identified and reported any concerns to the local authority and worked with partners to address those concerns and to protect people. However, the management team did not consider all people’s feedback, complaints and reports of significant delays in care visits as potential safeguarding issues. This put people at risk of neglect and was a breach of regulation in safeguarding. Staff received safeguarding adults and children training and knew how to recognise and report any concerns. Staff told us they completed online and face to face safeguarding training and were able to give examples of signs which may indicate someone is at risk of abuse or neglect. Staff told us how they would report any concerns to the management straight away. One staff member said, “I go to manager. Whenever I (have a concern), I call the office and they will advise me what to do. I can go to CQC or social worker as well.”

The provider’s systems did not always recognise issues raised by people, their representatives and staff as safeguarding concerns where required. For example, in relation to complaints or care visits timings. The provider had systems and processes in place to safeguard people. Staff received safeguarding adults and children guidance and training at the point of induction into the service and completed safeguarding training. The provider had a safeguarding policy referring to the local authority safeguarding teams contact details and the relevant guidance. There was a whistleblowing policy in place as well.

People and their relatives told us delays and inconsistencies in care visits prevented staff from providing required support timely which negatively affected their experience of care. We informed the local authority about people’s feedback. When staff did attend, some people were satisfied with the level of care provided, others were not.

Despite staff having access to people’s care plans and risk assessments, risks were not always well managed due to people not receiving their care visits, or their care visits being cut short. Staff told us how they supported people to ensure they were mobilising safely, around their personal hygiene and continence or skin care. Staff gave us examples of how they encouraged people to eat and drink to prevent risk of dehydration and malnutrition. Staff’s feedback was matching people’s individual care plans and risk assessments we reviewed. However, staff also told us they were not always able to attend people’s care visits on time which put people at risk of their needs being neglected.

Processes to ensure risks were managed safely were inadequate. People had individual risk assessments and care plans in place. For example, around personal care, mobility, skin care or nutrition and hydration. People’s care plans included information around their specific health needs and risks. However, due to inconsistencies in care visits timings which were not effectively actioned by the provider at the time of the assessment, people did not always receive their care as planned which put them at risk.

People and their representatives were not always happy with the way staff supported people to maintain a safe, hygienic and comfortable environment in their homes. Some people were complimentary about how staff ensured they were supported to live in clean and comfortable environment, for example, by providing daily support with cleaning and house tasks. Other people and relatives told us their experiences were different. For example, they were concerned about how staff supported people around safe preparation of food or cleaning their equipment.

Staff told us they had all required information available on the electronic care planning system and were aware of how to support people to maintain safe environment and how to keep themselves safe when in people’s homes. However, people told us this was not always their experiences of staff practice.

Processes to ensure people were supported to maintain a safe environment were not effective. People’s care plans assessed people’s home environment, although the assessment was generic across all the care plans we reviewed. The care plans referred to keeping the environment clean and tidy and safe for the person. Environmental factors and safety were discussed in staff meetings. The provider had a business contingency plan in place which supported them to manage unforeseen emergencies and events which could affect the health and safety of staff and people using the service. The registered manager noted any actions taken to manage such events on a log and monitored any impact of those events. However, people and their representatives told us staff did not always adhere to the plans and processes in place when supporting them.

People and their relatives told us their care was not always provided timely, for the required amount of time and by a consistent group of skilled staff which impacted on their quality of life and delayed support required to meet their individual needs. People commented, “Mornings I’ve been asking for ages to be before 10am because they were getting later, and later, to sometimes 1 or 2 in the afternoon. Sometimes I ask can if they can come before 10am they say they go by what they have received. There is such a wide range of [staff] it’s hard to get to know them. The time keeping is the main thing I am not happy with. I keep ringing and asking. I have to phone up and ask who I am having for the next 2 days. If I didn’t phone up, I wouldn’t know”, “Sometimes they are knocking at 6am, sometimes at 9am. There is no routine. Sometimes they come at 11pm (which was very late for the person)”, “[Staff] have rung me before (when running late) but when they have new staff, I don’t always get a call. They are getting more in the timeslot they are supposed to be.” People told us the lateness affected their day to day lives and sometimes meant staff did not have an opportunity to check on people and provide their care when it was most needed, for example, when people were alone for long periods of time without help around their mobility or continence needs, when they needed help to prepare a meal to take their medicines on time or when they wanted to have visitors or to go to bed but they could not as they were still waiting for personal care.

Staff told us roster planning had been improving in the recent weeks but there were still issues which needed to be resolved. Some staff now had breaks and travel time included in their rosters and their working time was more manageable. Other staff told us they were not always able to reach people on time and stay the required amount of time. Staff said, “There is no travel time at all. I have to start at 05:30am and I don’t finish until 10pm”, “[Staff] will be late. We try to juggle our time, but it does cause issues and it makes you feel uncomfortable when you get to the house. We raise it every time in staff meetings”, “Sometimes I have enough time, sometimes I don’t. We told the managers this. They said they were going to do something about it, but they haven’t. I tell the clients I’ve been caught in traffic because then they don’t mind. It makes me feel pressured. I don’t cut calls short; I do what I need to do, but it means that by lunchtime I am running very late. We have raised it.” Staff told us they were provided with induction and ongoing training, including practical and face to face training course, direct observations of their practice and supervisions. Staff said, “I really do feel supported. I have had training and management do random spot checks” and “Induction and training was okay. It was face to face and e-learning. I learnt a lot. I have had recent supervision.”

Processes to ensure safe and effective staffing were inadequate. The provider’s electronic care visits monitoring report for June and July 2024 evidenced multiple care visits were late, some for more than 2 or 3 hours. People’s records we reviewed showed care visits were often cut short and staff did not stay the planned time to offer further support. Staff rosters for 3 staff members showed staff were still allocated care visits without travel time. The management team told us rostering issues were identified few months before and they told us of actions they took to address the shortfalls. However, this work was not completed at the time of the assessment and the contingency plans in place were ineffective. People were not always receiving the care they needed timely which put them at risk of avoidable harm and decline in their quality of life. This was a breach of regulation around staffing. New staff were recruited safely. Staff received in house induction and mandatory training.

People told us staff did not always follow safe infection prevention and control practice when supporting them. Relatives commented, “I have said this a couple of times to [the registered manager] or her colleagues, when it is cold we get carers coming in with coats on. You can’t wash your hands properly. I think they have slipped a bit with that. They don’t wear disposable aprons and they rely too much on gloves. They know even if making a cup of tea, you take your gloves off and wash hands before going in the kitchen. Some do, some don’t. They think they are protected by gloves the whole time in the house.” Other relatives told us staff did not always change bedding appropriately to ensure it was dry and clean and they had concerns around how staff cleaned people’s toileting equipment. Some people told us they were happy with staff practice, “[Staff] always take their gloves off and use the bathroom to wash their hands. If I saw poor hygiene, I would be saying something” and “[Staff] are very good at cleaning, (everything is) nice and tidy.”

Staff told us they knew how to ensure good infection prevention and control and had relevant training. Staff commented, “We have training about personal protective equipment (PPE), how to prepare it. [The management team] told us how to prevent infection, how to wear PPE. This was a training in person at the office” and “Whenever I see my PPE is being finished, I go to office to collect it.” However, people and their representatives told us their experience was not always positive and not all staff knew how to adhere to good infection prevention and control during the care visits.

The provider had infection prevention and control systems and processes in place, but these were not always effective in ensuring safe practice. Where concerns were identified during staff spot checks, there was limited assurance how this was followed up and addressed with individual staff. For example, there were practice support needs and shortfalls identified in 2 recent staff spot checks but there was no recorded evidence of how this was addressed with the staff members at the time of the assessment, although the provider shared evidence of action taken to support 1 staff member following the assessment. The provider had infection prevention and control (IPC) policy in place and completed checks around personal protective equipment and IPC systems in the service. However, people and their representatives told us not all staff demonstrated adequate skills and safe practice in this area when supporting them. The provider failed to ensure good infection prevention and control practice which put people at risk of spread of infections. This was a breach of regulation in safe care and treatment.

People told us they overall received support with their medicines and staff were competent to support them. However, people and their relatives also commented the delays in care visits sometimes affected their ability to take their medicines on time and as prescribed. This put people at risk of not taking their medicines as prescribed which could cause avoidable harm. Many people supported by the service were independent with taking their medicines. Those, who needed assistance or support, received it during their care visits and this was assessed in their individual care plans.

Staff could explain to us how they supported people around their medicines and told us they received appropriate training and competency checks in medicines management. One staff explained how they supported a person with specific needs around their medicines and this was in line with this person’s care plan which we reviewed. Staff said, “I assist, and I prompt (people with their medicines). I’ve had a recent check on my practices” an “I give [medicines] according to what was prescribed. We fill the (electronic medicines) record individually and we can access this on the phone.” The registered manager explained how medicines administration was monitored, audited and how they addressed issues around gaps in medicines records with staff. However, due to inconsistencies and delays in care visits, people were at risk of not receiving their medicines as prescribed which could put them at risk of avoidable harm.

The provider’s systems and processes for safe medicines administration were not always fully followed at the time of the assessment. People’s medicines records were not always fully completed by staff as per provider’s policy and did not always reflect what support people were provided with. For example, there were gaps in signatures or explanation of support provided in all 5 medicines administration records we reviewed for those people who received support with their medicines. The registered manager had some level of overview and checked within people’s care notes if people received their medicines as prescribed. However, there was limited assurance on how this was monitored and effectively actioned daily to ensure people received required support timely and to action any discrepancies, for example, when medicines were recorded as missed, not available or were said to had been refused by people. The medicines record keeping was being addressed by the registered manager during team meetings and by providing further training for staff. However, actions taken at the time of the assessment were not effective in rectifying the identified shortfalls, so people were at risk of not receiving their support with medicines as required putting them at risk of avoidable harm. This was a breach of regulations around safe care and treatment in relation to safe management of medicines. The provider assessed risks and individual people’s support needs around medicines within their care plans.