Wellbeing Assured Healthcare - Main Office

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• 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 identified breaches of regulations in relation to safe care and treatment and good governance. The provider had ineffective and unreliable systems for identifying and managing risks. We were not assured that incidents were appropriately identified, recorded, investigated and reported. The provider did not demonstrate a collaborative, joined-up approach to ensure people’s safety. They also failed to identify and manage the risks that people faced when they needed to be assessed or move between services. The provider and staff failed to recognise and safeguard people from frequent incidents that put people’s safety and wellbeing at risk. The provider did not always take a proportionate approach to imposing restrictions on people. People’s care plans failed to effectively reflect any foreseeable risks that may need restrictions. The provider’s systems and processes for ensuring safe and effective staffing were unreliable. The provider did not demonstrate an effective approach to assessing and managing the risk of infection. The systems and processes for ensuring people always received their medicines safely were ineffective and inadequate.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals told us that people did not experience a culture that was safe. People experienced unmanaged risks and repeated incidents, which demonstrated that lessons were not learned when things went wrong.

The provider lacked understanding with regard to identifying concerns, reporting incidents and taking appropriate action to ensure lessons were learned and recurrences could be avoided. However, staff told us if things went wrong in the service, the registered manager was immediately informed, quick follow ups took place and meetings were held with staff. This helped them to learn from what had happened and also be prepared with solutions if it happened again. One staff member said, “If something goes wrong, the information can be shared with the right people in authority, an investigation will be carried out and, if needs be, more training can be completed to educate people.” The registered manager told us they discussed issues and incidents with staff, but we saw that some incidents were only acted upon after they had been identified by external professionals, including CQC.

The provider had ineffective and unreliable systems for identifying and managing risks before incidents happened. We were not assured that incidents were appropriately identified, recorded, investigated and reported. We asked the provider for summary of accidents, incidents, deaths, safeguarding concerns and complaints for the last 6 months. We also asked for details of any investigations, action taken and lessons learned. The information we received was very sparce and lacked clear detail. Information relating to any incidents that were person-specific, had not been carried over to people’s care plans and risk assessments, which would help ensure staff knew what action to take to avoid or prevent recurrences.

The provider lacked understanding of how people should be supported to experience safe systems, pathways and transitions and make informed choices regarding where they lived. The provider told us that, because an eviction notice had been served on one property, they were moving the people using the service to new accommodation that they had sourced. The provider told us they had taken people to show them the new property and people had said they were looking forward to moving to their new home and were ‘nervous and excited’ about it. However, the provider’s actions were not in collaboration with people’s relevant funding authorities and barriers were put in the way, which caused delays in people having their needs reassessed. This meant people were not supported by safe systems, pathways and transitions and they could not make informed choices about where they lived, because prospective new care providers had not been able to assess people.

The local authorities, who funded the placements of people using the service, shared concerns with us regarding people’s safety and a lack of collaborative working by the provider. Due to these concerns, they said they were trying to have people’s needs reassessed, so they could move to new care providers. A placement manager from 1 local authority told us, “Currently we are trying to move [person]. However, the provider are not appearing to be supportive in this matter or understanding the urgency.” The landlord of 1 property had served an eviction notice for the tenants to move out by 23 October 2024. The provider told both the local authority and CQC, that this date had been extended to 30 November 2024. However, the landlord told us that they had only agreed to an extension up to 20 November 2024. A placement manager from the local authority told us, “It is a huge concern that in a matter of 1 year our service user has had to move twice [whilst being supported by Wellbeing Assured] due to the issues with landlord/rent.” Other local authority staff also told us how the provider had been uncooperative and had not supported people to have assessments completed in a safe and effective way. For example, prospective care providers reported they had not been able to complete assessments, because people had not been available at the times of prearranged appointments. The provider made appointments with two prospective care providers for the same time and date. The provider told them they should complete their assessments with a person one immediately after the other. This did not demonstrate consideration for the mental wellbeing of the person using the service.

The provider did not follow effective processes, to ensure safety and continuity of care was a priority throughout people’s care journeys. They did not demonstrate a collaborative, joined-up approach to ensure people’s safety. The provider also failed to identify and manage the risks that people faced when they needed to be assessed or move between services.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals told us that people did not experience a safe environment that would help protect them from abuse, neglect and unsafe practice.

The provider and staff failed to recognise and safeguard people from frequent incidents that put people’s safety and wellbeing at risk. However, staff told us they understood how to keep people safe from abuse and knew what action to take if they had any concerns. One member of staff told us they had not had any situations which required them to report a safeguarding concern yet, but they had read the company policies and procedures and would follow these if needed. Another staff member explained a situation where they recognised a person may be at risk and had raised a safeguarding concern.

The service had safeguarding policies and procedures in place. However, we were not assured that the systems and processes and the staff training for safeguarding were effective. This was because staff and management failed to identify where people’s liberty was being restricted, without appropriate or legal guidelines and authority. Staff and management were not consistently working in accordance with the principles of the Mental Capacity Act 2005. Information we read in people’s care plans and daily records gave examples of restrictive practices, such as tracking a person’s movements, confiscating and destroying items owned by a person and restricting a person’s access to their money, alcohol and tobacco. One person was deemed not to have mental capacity in some areas of decision making but there was no authorisation for restrictions from the Court of Protection. There was also no record of the decision-making process, to demonstrate that decisions were being made in the person’s best interests. One person was deemed to have mental capacity and had signed a consent form for Wellbeing Assured Healthcare Ltd to support them to ‘handle and manage their daily alcohol and tobacco usage’. In addition, it was stated that the service managed the person’s money and gave them a daily allowance. However, there were no clear guidelines, care plans, risk assessments or protocols for staff to follow. This meant the person was at risk of not knowing what the agreed boundaries were. There were also gaps and discrepancies on the person’s ‘Account Management Sheets’. Some staff signatures, dates, descriptions and balances were missing and there was no confirmation that receipts for purchases had been obtained. This meant the person was not protected from financial abuse.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals told us that people did not experience a balanced and proportionate approach to risk that supported people and respected the choices they made about their care.

Staff told us that people’s care plans and risk assessments were clear and detailed. However, one member of staff told us, “There are some days I find it very difficult to complete my task especially when service users’ mood changes negatively.” We looked at people’s care plans, risk assessments and daily notes, but there was no information or guidance for staff, to show how staff should support people in a situation such as this.

The service did not always take a proportionate approach to imposing restrictions on people. People’s care plans failed to effectively reflect foreseeable risks that may need restrictions. All the risk assessments for the people receiving the regulated activity were of very poor quality. They lacked clear and accurate detail and there was insufficient guidance for staff to support people to understand and manage risks to their health, safety and wellbeing. There was incorrect information about people’s needs, which could lead to confusion. One person was stated to be ‘at risk of incontinence’. One section of their care plan stated this was because they suffered from a colostomy. Another said it was due to a colonoscopy. Both stated this was, “a medical condition that affects the ability to pass urine or open your bowels.” Information about the person’s continence support requirements was varied but there was nothing to explain their actual diagnosis, nor to say whether the person could be supported to manage their continence more independently. One person’s risk assessment stated they experienced mood swings and could act inappropriately if they saw women. The risk management plan stated, “Assign male care staff at odd periods and minimise exposure to opposite sex and pregnant women.” However, the rota showed most shifts were covered by female staff and no male staff were on duty Fridays to Mondays. There was no information to explain what action should be taken if the person was affected by having female staff supporting them. One person required a catheter, which their care plan said they managed independently when mentally well. However, it was also stated that they regularly removed the catheter, which needed to be refitted by the district nurse or at the hospital emergency department. There were no specific care plans or risk assessments for catheter care, nor guidance on how to identify and manage associated risks, such as infections that could lead to sepsis.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals told us that people did not experience care and support within environments that kept them safe and secure, physically and psychologically.

The provider told us that, due to people’s eviction from 1 property, they had secured a tenancy on a new property for people to move to. However, we identified they would not be registered to provide the regulated activity at the new premises. We also identified that the provider was supporting a person in another property, with a regulated activity they were not registered for. This meant the provider did not understand how to ensure people were cared for and supported in safe environments that were designed to meet their needs.

We were not assured that the provider had effective systems and processes in place to ensure the environment remained safe for people to live and work in. Although people had individual tenancy agreements in 1 property, the local authority told us the provider did not have any formal system in place for when repairs or maintenance issues were identified. They said it was unclear on how these were raised and recorded and there was also no clear process for people using the service to report issues independently.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals told us that people could not be assured they would be supported by staff who had been safely recruited and were suitably experienced and competent.

Information given to us by the provider, including the rotas and people’s daily notes was contradictory and did not tally with what the provider and staff told us. Staff told us that there were enough staff to support people. They said they received regular supervisions and completed appropriate training. Staff told us that, where applicable, their sponsorship conditions were met and they only worked the number of hours they were allowed. The provider told us that staff provided a live-in service at 1 property, where there was only 1 person using the service. They said they provided day staff, waking night staff and an on-call service for 3 people who lived at another property. However, the rotas did not show how or which staff provided night support at the property with 1 person. There were gaps on the rotas for the property with 3 people and these did not match people’s daily notes. There was also no confirmation of who the ‘on-call’ person was or how to contact them.

The provider’s systems and processes for ensuring safe and effective staffing were unreliable. The staff rotas gave unclear and inaccurate information about which staff were on duty in the different supported living schemes. There was a system for providing managerial and staff cover when staff took breaks, but the planned schedule for this did not adequately ensure the schemes were appropriately staffed. The manager told us staff provided a live-in service at a property for 1 person. A member of staff told us they worked 20 hours per week supporting this person and the rota stated they worked from 9am to 8pm, with a 1-hour mandatory break, 2 days a week. However, we saw this member of staff was officially on duty for 24 hours at a time, which meant they should be paid a sleeping allowance in addition to their 20 hours. The daily notes also referred to instances where this member of staff had supported the service user at 6:30am and after 11pm. This meant they were regularly working outside of their stated hours. The training matrix showed that some staff had not completed training, which was required to ensure people’s needs were safely met. For example, 7 staff (including the registered manager) covered regular shifts in a property where a person had a catheter. However, the manager’s training was not included on the matrix and 3 other staff had not completed training in catheter care. Only 1 member of staff had completed training in Positive Behaviour Support and this person was the administrator, who provided ‘break cover’.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals told us that people did not always experience appropriate support to understand and manage the risk of infection.

Staff told us they had completed training in infection prevention and control and the training matrix supported what they told us. A member of staff told us, “I consistently use PPE (Personal Protective Equipment) during my shifts to ensure both my safety and that of the residents. I always make sure to wear the necessary protective equipment, such as gloves, masks, aprons, and any additional PPE required for specific tasks. Generally, there’s a reliable supply of PPE, although there are occasional instances where certain items run low, but these are usually resolved quickly. Having adequate PPE is crucial, and I prioritise maintaining safe, hygienic practices in all care activities.”

Although staff had completed training about infection prevention and control, the provider did not demonstrate an effective approach to assessing and managing the risk of infection. The monthly quality monitoring form and action plan included a section for health and safety, but there was no reference to infection prevention and control. Feedback from the local authority’s quality monitoring team said there was no formal cleaning schedule in place.

We were not able to speak directly with the people using the service. However, feedback and evidence from other professionals and records we looked at told us that people did not always experience safe support and guidance in respect of the management and administration of their medicines.

One member of staff told us they had completed medicines training, but they were not yet authorised by the company to administer medicines. However, we noted that this person covered waking night shifts alone from Mondays to Thursdays. This meant that they would not be able to administer people’s PRN (as required) medicine if they required it during the night. The manager told us there was on-call cover, but there was no confirmation on the rota of who the ‘on-call’ person was, how to contact them, or whether they were trained to administer people’s medicines. Other staff told us they had completed training for managing and administering medicines. One member of staff commented, “Having received adequate training on medication administration and handling, I feel more confident supporting individuals with their medication needs, ensuring that each person receives their medication safely, accurately, and at the right times. I follow strict protocols and double-check details to avoid any errors.” However, we identified inaccuracies throughout people’s medicines records, which contradicted this statement. For example, one person’s medicine was stated to be 500mg on the header page but only 50mg on the medicines administration sheet. Another person’s medicine was stated to be 10mg on the header page, but the medicines administration sheets state the doses being given were 25mg.

The systems and processes for ensuring people always received their medicines safely were ineffective and inadequate. We found numerous errors and discrepancies throughout all 3 people’s medicines records, which put them at serious risk of harm. The registered manager had signed and dated, on a weekly basis, “All medication checked and confirmed to be accurately administered”. However, the auditing system was not reliable, as it failed to identify repeated errors. For example, we saw that medicines had not always been signed for and there were cases where it was evident a person’s medicine had not been administered as prescribed. We noted that 1 person had not received a medicine for 2 days, because it had run out. One person usually took their medicines in the morning but, on occasions, they stayed away from the service and did not return until the following night. There were no protocols or risk assessments for managing and administering the person’s medicine while they were away. Records showed occasions where the person had been given their medicines over 12 hours late, then their next dose given within 12 hours. Medicines records were still marked as administered at breakfast, even though daily notes confirmed it had been night. We checked NHS guidance and found 1 particular medicine should be taken at the same time every day and if the dose is more than 8 hours late, it should be omitted completely. The guidance also stated that a missed dose could make the medicine less effective, cause withdrawal symptoms and increase the risk of a relapse in a person’s mental health. The medication stock count form was also not completed in real time. One person’s ‘time of count’ was completed at exactly 18:00 every Wednesday. The provider gave us a copy of people’s medicines records on Tuesday 29 October 2024. However, we saw the ‘amount administered’ section had already been completed for Wednesday 30 October 2024.