Pioneering Care Bicester Limited

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 assessed 6 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating for the last inspection, our rating for this key question is inadequate. We have identified 4 breaches of the legal regulations. People were not routinely protected from abuse, the service failed to always recognise or act on allegations of abuse. The risks to people because of their medical conditions were not always assessed in a timely manner to prevent harm. Where risk assessments were completed these did not always mitigate the potential harm to people. Where concerns were reported about changes in people’s health there was no evidence of action to report to family members or health professionals. Medicines were not always managed safely. People went without their prescribed medicines and medicine records were not in place for all medicines staff had administered. Body charts were not in use for topical creams and guidance was not provided for all “as required” medicines that were administered. People were not routinely supported by staff who had been suitably recruited which had the potential for an increased risk to people. Staff working in specific roles did not have effective training to ensure they had the skills and knowledge to support people safely.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experience with the service varied. Some people felt communication was good, whilst others felt communication was poor. Some people had experience of being asked for their view on the service, whilst others could not recall if their views were considered to promote learning. A person told us they have in the past been made to feel like they have no right to complain and that prevented them from raising issues.

Staff told us that they received updates regarding learning from incidents via the use of email, team meetings, or where necessary a phone call. Staff we spoke to were unable to give an example of these updates of learning. Staff were aware of reporting procedures for accidents and incidents. However, they were not required to fill out documentation and did not always receive feedback following concerns raised. The nominated individual told us that lessons learnt were documented within people’s logs and communicated with staff at team meetings.

Processes were not robust to ensure continuous learning. There was no oversight in place for accidents and incidents. The nominated individual told us they do not have central oversight for incidents and accidents, and there was no monthly monitoring. There were no quality assurance processes in place, therefore shortfalls in people's care records meant staff and management were unable to learn from findings to improve the quality and accuracy. Any accidents or incidents were reported to the office. The office had a log of issues reported to the office by staff. However, there was no evidence of review by office staff and no evidence that action was taken to promote learning, mitigate risks and prevent reoccurrence. For example, a person had experienced an increase in falls. The risk assessment was not updated to reflect the increase in falls to mitigate risks and prevent reoccurrence. There was insufficient oversight of safeguarding concerns, which meant the organisation had not analysed these concerns to identify trends or patterns. Additionally, there was no action plan in place to address the outcomes and recommendations from safeguarding reviews which resulted in failures to safeguard people.

Staff told us they worked alongside other health professionals and took advice from them. However, people's records did not evidence that joint working was promoted to ensure safe systems, pathways and transitions for people.

Some professionals were positive about the service, but others felt staff missed subtle signs of deterioration in people, relied too heavily on GP advice, and blurred the distinction between physical and emotional health, leading to a deterioration in a person’s health and well-being.

There was no established process or policies in place for monitoring changes in people’s health. We saw staff reported concerns to the office about changes in a person’s health. There was no evidence this was actioned or escalated to professionals such as the GP. In another person’s file we saw it was recorded frequently that their catheter was leaking instead of draining. There was no indication medical advice was sought. Care plans did not routinely include assessments undertaken by other professionals / services involved in people’s care and there was no evidence the service had involved them. Staff did not have an awareness of people’s risks on discharge from hospital back to home. There was no monitoring of potential risks, no continuity of care work and no evidence that views of people and family members had been sought to promote a safe transition from hospital back to home.

Whilst most people told us they generally felt safe, evidence found during this assessment demonstrated that systems and processes in place were not effective in ensuring risks to people were mitigated and people were kept safe from abuse. A person told us they did not feel safe as staff did not have knowledge of their condition or support them appropriately during the care call. They felt unable to raise concerns for fear of retaliation. This was fed back to the local authority safeguarding team to safeguard the person.

Staff we spoke to felt that people using the service received safe care. Staff were aware to report concerns to the office but were not aware who to report safeguarding concerns to, outside of the service. Feedback on issues raised was not routinely provided and therefore, staff were not aware if issues raised by them were addressed. Staff spoken with lacked an understanding of the Mental Capacity Act 2005 and Liberty Protection safeguards. A staff member told us the Mental Capacity Act was about treating everyone fairly, with respect, to enable them to lead a normal life. Another staff member involved in assessments told us they did not complete mental capacity assessments and that those are in place when they take on packages of care. They stated, “District nurses or the GP decide on mental capacity assessments”. However, in care records viewed we saw the staff member had completed mental capacity assessments which were not in line with the requirements of the Mental Capacity Act 2005, in that they were not decision specific and best interest decisions were not routinely recorded.

Safeguarding systems were not effective. The safeguarding log contained safeguarding’s which had not been raised with CQC or with the local authority safeguarding team. During the period of 2023 and 2024 only two safeguarding alerts had been made by the service to the local authority safeguarding team, even though records reviewed by us and concerns we had received evidenced there were other incidents of abuse that went unreported. In the safeguarding log the immediate actions taken to keep people safe were often blank and not always documented. The concerns log included allegations of abuse such as rough handling, shouting, rushing care and bruising which had been reported to the providers office but not acted on to safeguard people. The provider’s safeguarding policy was undated and not developed in line with multi agency safeguarding procedures. It outlined allegations of suspected abuse will be reported immediately to the proprietor, who will review the evidence and take the appropriate action. The policy outlines action might include informing other organisations, including the local authority safeguarding team. The policy was not clear that the local authority safeguarding team should be informed as soon as an allegation was made as they are the lead agency for investigating allegations of abuse. The service had no policy on consent to ensure they worked to the Mental Capacity Act 2005. The training log showed no staff were trained in the Mental Capacity with only the management of the service trained in Deprivation of Liberty Safeguards. Mental capacity assessments (MCAs) were not decision specific and information around people’s ability to consent and understand information was conflicting throughout care plans. ‘A person whose care plan was contradictory as to whether they lacked capacity, had bed rails in place without an MCA to assess and record their capacity on this specific decision. There was no record the decision was in their best interest.

Some people were not aware of risks to them or whether risks had been addressed. Some people felt involved in care plan reviews, whereas other people were not aware of reviews taking place. A person told us the risks to them were not managed as some staff failed to listen and support them in the way they required.

There was a failure to understand the regulatory responsibilities around risk management to ensure all risks had been considered and assessed so people were safe. Care planning contained contradictory and missing information about people’s needs which would not allow for consistent safe and personalised care. Risks to people's care were not always managed safely. While staff were aware of some risks, they lacked information on others, such as diabetes, epilepsy or choking, as this critical information was missing from people’s care plans.

Robust processes were not in place to keep people safe and mitigate risks to them. People’s risks were not always assessed, and their care planning was not updated following changes to people’s needs. They did not always include information such as how people liked to receive their personal care. For example, a person on end-of-life care did not have an end-of-life care plan in place. The care plan was not reflective of the support required from staff, professionals, equipment, risk, or the person’s physical ability. In another person’s care plan, it was recorded they had an allergy to many things. The allergy was not identified and therefore not mitigated. Staff were involved in the person’s meal preparation without that knowledge. This placed people at risk of unsafe care. People did not consistently experience care from staff who were aware of the nature and risks of the health conditions people lived with. There were no risk assessments in place for risks associated with seizures, mobility, personal care, environment, diabetes, falls, epilepsy, equipment, skin integrity, bed rails, swallowing, choking, self-neglect, and nutrition/hydration. This meant people could not be assured of safe and effective support. Daily records were of poor quality and did not always reflect the detail of care provided. They evidenced poor staff practice around toileting and lifting people without equipment after a fall. In a person’s daily record, staff had recorded, “We checked pad and cleaned soiling but saved the pad”. In another person’s file their daily records showed staff lifted the person from the floor to their bed with the assistance of a family member with no reference to using equipment. These practices did not promote safe care. The service had no risk assessment policy in place to provide guidance on risk management. Whilst office staff were trained in risk management the records showed they lacked the knowledge and skills to identify and mitigate risks to people.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Whilst people were happy with their care, they told us care was inconsistent in that they did not always know who would walk through their door and on occasions the visits were cut short and ran late. A person commented, “Sometimes staff cut short the visit, they have tasks on their phone, and some check their tasks, others are out of the door before they come in and gone within 10 minutes. Not all are like that but there is no consistency. A few staff are absolutely fantastic, but there are others that when they walk through the door my heart sinks, and some do not ask and it’s like a roulette as to who is coming and the type of care they give.”

Staff we spoke to felt there were enough staff available to support the number of people using the service. They confirmed they often took on extra shifts to ensure the calls are covered. Whilst staff confirmed they received spot checks, supervision and regular check ins from the management team we saw issues reported to the office about staff practice was not followed up at spot checks and supervisions. Staff told us they had access to training to do their job. However, the records viewed showed all staff were not suitably trained to meet people’s needs.

Staff were not suitably trained in their roles. The service did not have a training policy in place to outline the arrangements for the induction and training of staff. The training matrix for online training showed a total of 22 staff employed by the service. The matrix showed gaps in training. For example, 6 staff overdue training in infection control and health and safety, 4 staff overdue food hygiene training, 5 staff overdue first aid awareness. 3 staff are overdue training in safeguarding and 2 staff are overdue training in whistleblowing. The nominated individual provided us with an outline of what mandatory training is required by managers, team leaders and carers. However, all staff delivering care were not trained in diabetes, dysphagia and choking, eating and drinking, End of Life care, bed rails, Control of Substances Hazardous to Health (COSHH) and no staff were trained in epilepsy and people expressing distress/agitation, despite supporting people with these conditions. Management were trained in privacy and dignity, person centred care, equality and diversity and recording and reporting. However, those training areas were not deemed mandatory for staff going into people’s homes and delivering care. Staff were trained in delegated health care tasks by staff trained as train the trainers. We saw one of the trainers were delivering this training and signing staff off as competent when their ‘train the trainer’ certificate expired in July 2024. Recruitment procedures were not always operated effectively. The service did not have a recruitment policy to support their practice. Required recruitment checks such as references and a Disclosure Barring Service check had been received after staff had started employment, without a risk assessment in place. There was no health condition risk assessment in place for staff regarding their capabilities as a result of a medical condition and interview questions were not appropriate for the job applied for.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some people self-administered their medicines, whilst others required staff support with their medicine. A person who was self-medicating told us” I self-medicate as I would not trust the staff to give me my medicines.” They told us this was due to the inconsistency in call times and calls being rushed.

The nominated individual described the process around medicines, which included online training and a face-to-face assessment. Staff told us they felt confident administering and supporting people with their medicines. However, not all staff were sure if they had achieved an assessed level of medication competency. This would ensure they were safe and competent to administer medicines. The delegated health tasks records showed staff were trained and assessed to administer medicines. Whilst staff told us they were trained in medicines management we found safe medicine practices were not promoted as medicine administration records showed staff were not always administering medicines in line with best practice guidance on medicine administration.

Medicines were not always managed safely. Body maps were not in place for people who were prescribed creams, and prescriptions did not always indicate where creams were to be applied. In one person’s records we saw creams were applied for 4 days without a medicine administration record in place. In another person’s record we saw they did not receive support with their ‘as required’ (PRN) medication as the medicine had been taken off the medicine administration record. Staff told us they believed this was due to not being able to read the prescription. The family and care staff were giving one person morphine, and family leaving medicines for staff to prompt person to take. A medicine administration record was not in use to record when the family member or staff had administered this medicine. This is not safe practice which had the potential for the person to be overdosed. A person was prescribed medicine to use in the event of an allergy with no guidance in place on its administration. Another person’s medicine was out of stock for 4 days with no system in place to remind the family member a prescription was required before stock ran out. Whilst the nominated individual told us systems were in place to audit medicines, they confirmed medicine auditing had not been conducted recently. They were unable to provide us with evidence of any samples of medicine audits that had taken place. The medicine policy was undated and brief. It was not in line with best practice guidance to include guidance for staff on the safety and administration of controlled drugs, transdermal patches, covert medicines or over the counter medicines. There is a topical cream and ointments policy which includes guidance on opening dates of creams but does not include reference to the use of topical medicine administration records (TMAR) and body maps.