Deep Heart Care Wiltshire

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this service since it registered on 6 October 2023. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The provider was in breach of legal regulation in relation to the medicines management of the service and staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Incident forms had been completed when incidents occurred. However, there was incomplete information about people’s possible injuries and actions taken. The registered manager reviewed all incident forms; however, ongoing actions were not always recorded. For example, there were records of people needing to go to hospital as they had been found on the floor when staff arrived. But there was no record of potential injuries, or any further actions taken by the staff to mitigate risks of recurrence.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. When people needed referrals or assistance from healthcare professionals’ staff did not follow up on actions needed. We saw 1 record for a person who needed additional equipment. Staff had recorded they had tried to call the local surgery but were not able to get an answer. There was no other information recorded, and staff had not persisted to telephone healthcare professionals until they got a response.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. We found incidents of safeguarding which had not been shared with the Care Quality Commission (CQC). Whilst the provider had raised concerns with the local authority CQC had not been notified. The provider had a safeguarding policy which outlined what levels of training staff and management needed. Staff had completed safeguarding training but not the level outlined in the policy. Also, the registered manager had not completed the management training for safeguarding as outlined in their policy. We spoke with staff, and they understood what they needed to report and told us they would share concerns with the registered manager.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people’s safety had not always been identified so that management plans could be produced. This meant staff did not have guidance needed to support people safely. For example, one person had a diagnosis of epilepsy. There was no risk management plan for this person for staff to know what to do should the person experience a seizure. For another person with a catheter, there was no risk management plan for staff to know what the risks were in relation to catheter care. Where risk management plans were available for some risks, we found information that was conflicting or inaccurate.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Some people told us they were not confident about staff being able to use facilities in their homes. For example, people shared concerns about staff not being able to operate a shower or a microwave. The registered manager told us they made it clear to staff they must ask if they were unsure about any equipment in people’s homes. The registered manager told us they assessed the risks in the environment such as gas safety, lighting and risk of flooding.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. Staff had not received training needed to make sure they could safely meet people’s needs. For example, staff supporting people with epilepsy had not received training on epilepsy and management of seizures. Staff supporting people with a learning disability had not received mandatory training for care staff. There were enough staff to cover care packages, however, some people told us their care worker was often very late or did not arrive at all. The registered manager told us they had only experienced 1 missed visit in the last 6 months which was due to flooding. Prior to this there had been some missed calls but recruitment had been successful. Staff had not always been recruited safely. Not all of the required checks had been completed consistently. Whilst the provider had obtained a Disclosure and Barring Service (DBS) check and references, they had not made sure all staff had provided a full employment history. We would expect the provider to be aware of this requirement.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff received training on infection prevention and control and were provided with personal protective equipment (PPE). Staff told us they had the PPE they needed and received additional stock in a timely manner.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning their medicines management. The provider used an electronic recording system for medicines administration records (MAR). However, due to poor network connectivity in some areas, staff were also using paper records. The paper records did not contain the information needed for MAR. This meant staff did not have information on why a medicine was prescribed, the prescribed dose for a medicine or when to administer all medicines. We found gaps in recording on MAR which meant the provider could not be assured people had their medicines as prescribed. Where people were prescribed ‘as required’ medicines there was not enough guidance for staff to know when to administer this type of medicine. We also found medicines prescribed for mornings were recorded as being administered in the evening. For 1 person their MAR recorded that they had taken their morning and evening dose of medicine within half an hour of each other. This meant the person was at risk of harm. Some people told us they did not feel staff had the training needed to administer medicines. Staff we spoke with all said they felt confident administering medicines and had been assessed as competent by their manager.