Pioneering Care Bicester Limited

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 6 quality statements in the well-led key question and found areas of concern. The score for the quality statements have been combined with scores based on the rating for the last inspection, our rating for the key question is inadequate. We identified 3 breaches of the legal regulations. The service was not appropriately managed to promote a high-quality safe service and comply with the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 and the Care Quality Commission (Registration) Regulations 2009. Good governance was not established with no internal or external auditing taking place to ensure the quality and safety of the service. People’s records were contradictory and not accurate. Records relating to the running of the service such as policies and procedures were not in place or not developed in line with best practice. The service failed to notify us of events that they are required to and failed to add the service user band autism and learning disabilities to their registration prior to commencing packages of care to people with autism and learning disabilities. Person centred care was not promoted, with care not reviewed and updated in a timely manner to promote safe care. Care plans did not identify the impact of medical and mental health conditions on people to enable staff to support them in a person-centred way.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were aware of their responsibility to provide safe care to people, however systems and processes did not promote this. A staff member commented, “I do not think the aims and purpose of the agency are defined. They are more implied as told at induction what is expected of us.” Whilst some staff raised no concerns about the culture of the service, whistleblowing concerns prior to the assessment and feedback from other staff as part of our assessment, described concerns about the culture of the service which did not promote a positive environment to work in. Some staff felt unable to raise concerns directly with the registered manager and found them to be reactive as opposed to proactive.

The service failed to notify us and the local authority safeguarding team of events which they are required to do. In the last 2 years since the previous inspection, we have had no safeguarding notifications from the service and only 2 notifications in relation to other events. This indicated a closed culture within the service. The service supported people with autism and learning disabilities. The service user bands autism and learning disabilities was not included on their registration. Alongside this, there was no guidance in place to promote right care, right support, and right culture to support staff in supporting autistic people and people with a learning disability.

We received negative feedback from some staff about the registered manager’s ability to manage the service, which did not demonstrate they were capable, compassionate, inclusive and did not promote a positive role model. Staff told us the registered manager was not a capable leader and lacked the experience to lead by example. Staff described being micromanaged and told us the registered manager had no insight and did not understand the impact of their leadership, personally or professionally on people around them. We saw in people’s records the registered manager did not identify the need to robustly assess people's health needs and to include people in these assessments. Care records shared with staff were not always in place or were inadequate and did not equip staff to provide a high quality and safe service.

During the assessment through discussions with staff and reviewing documentation we found leaders were not inclusive at all levels. There was no oversight of staff roles to ensure staff had the skills to carry out their roles effectively to promote safe practices. We could not always see that the registered manager had acted on information to safeguard people or what their role was in managing the day to day running of the service. We found staff lacked direction and guidance. This had resulted in a lack of consistent approach to the care and support of people. As a result, some people did not receive the right person-centred care and treatment when their needs changed. A lack of management oversight had led to risks for people using the service.

Prior to the assessment we had received whistleblowing concerns which alleged staff felt unable to raise issues and concerns, and when concerns were raised, they were not acted on to improve the care to people.

There were some systems in place for people and staff to provide feedback. However, actions were not routinely taken in response to feedback. We saw concerns reported by staff to the office were not consistently acted on to safeguard people. For example, a staff member had provided feedback on another staff member’s practice which was not addressed with them. Other concerns alleging abuse and poor practice were not acted on to safeguard people. Team meetings took place quarterly, and staff were provided with supervision and appraisals. Spot checks of staff practice and feedback from people on their care calls were carried out, but there was no evidence any follow up action was taken. Staff and people surveys were carried out annually. However, there was no oversight of responses, analysis of surveys and no action plans in place to respond to feedback. The service had a whistle blowing policy which was brief and undated.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The nominated individual told us they have no evidence of any samples of audits that had taken place.

Systems to monitor and mitigate risks and improve quality of care had not been implemented effectively. There were significant shortfalls in many of the records viewed. This placed people at risk of receiving unsafe care or care which did not meet their needs. There was a failure to understand the impact and importance of assessing people’s risks in full and ensuring staff had access to important information and guidance around health care conditions and risks to safely and effectively undertake their role. The provider had no systems in place for internal or external auditing of the service with limited oversight of practices in place to promote good governance. For example, there was no oversight of safeguarding, complaints and spot check actions. There were no audits in place for care planning, daily notes, and medicine audits had not been carried out in some time. Not having these audits and checks in place meant the service had failed to identify inconsistences found during the assessment around medicine practices, incorrect care plans, poor daily records, lack of risk assessments, MCAs not being in place and inconsistent information throughout people’s care planning. Policies were brief, undated and not developed in line with best practice guidance and required legislation. Other policies were not available. The business continuity plan was dated 2022 with no evidence of a review since its implementation. The business continuity plan was brief with no outline of what the contingencies are.

People were not aware if the service worked in partnerships with others. For one person we saw there was a delay in equipment being sourced for them and for another we saw concerns around their health was not reported to a GP.

Staff told us they worked in partnership with other professionals. A staff member commented, “We have a very good relationship with other professionals such as district nurses and palliative care team. We have just started a package of care with a person who has autism as the team know we manage that well.” However, from the training records viewed we saw staff did not have the training and skills for their roles which had the potential for people’s needs to not be met.

We received mainly positive feedback from professionals in relation to their recent engagement with staff at the service. However, we are aware from records viewed there was a failure by the service to report incidents to the local authority safeguarding team to enable the local authority to have an effective overview of safeguarding concerns about the service.

Whilst professionals were involved with people, daily records did not always indicate concerns were escalated to next of kin and professionals in a timely manner when required. There was no guidance for staff on partnership working and the lack of effective auditing of daily records meant the provider had no oversight of referrals required for or made to other professionals.

Staff confirmed incidents were discussed at team meetings to promote learning and improvement. The team meeting minutes viewed showed discussion on people using the service, but where risks were identified the service failed to put measures in place to mitigate risks and evidence learning. For example, in the team meeting minutes dated, 10 June 2024 it was recorded that a staff member was upset and deflated following a negative visit with a person using the service. The staff member was advised to challenge the service user’s behaviour in the visit and be assertive with them. They were told ‘If the visit is that bad, ensure the person is safe and leave’. A risk assessment was not put in place to outline to staff how to safely manage situations to prevent escalation by challenging the person. These practices did not promote learning and innovation to promote safe care.

Processes were not evidenced as being in place to ensure learning and continuous improvement. The systems and processes for improving quality had not always been effective, they were not established or operated effectively to ensure compliance with regulations by assessing, monitoring and improving quality of service. There were no action plans in place, which would be expected following all audit processes where these identified improvements were required. People were placed at risk, due to risks not been identified or mitigated. For example, the way their medicines and health were being managed, and risks around missing documentation. There was not always an accurate, complete record of care and treatment provided to people, to promote learning and improvement.