Warrens247 Healthcare Ltd

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 people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. 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 service was in breach of legal regulation in relation to managing risks and people’s safe care and treatment.

This service scored 53 (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. Accidents and incidents were recorded by staff and reviewed by the management team. However, improvements were required to ensure all accidents and incidents were appropriately dealt with by staff and action taken by the leadership team to reduce risks posed to people.

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. Whilst pre-assessments were in place prior to people receiving support from the service, these required improvement to ensure all information was sought at pre-assessment stages. For example, we found records did not contain people's full health diagnoses. Staff worked well with professionals, and we saw evidence of staff working closely with district nurses and occupational therapists. However, we found some accidents and incidents had not been dealt with appropriately.

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. Systems were in place to monitor safeguarding concerns; however, we found an incident which we had not been notified about. This was brought to the registered manager’s attention during our inspection and a notification was made to us retrospectively. We also highlighted 2 safeguarding incidents following people falling which we asked the provider to report to the local authority following our inspection. Staff understood their responsibilities to record and report safeguarding concerns and staff told us they felt able to whistle-blow on poor practice. However, some staff were overdue safeguarding refresher training. A staff member said, “Safeguarding is discussed in meetings and training. We’ve been encouraged to speak up if we ever witness anything wrong or that could harm people. It is important to maintain high standards of care and protect vulnerable people.” People and relatives told us they felt safe receiving support from the service, and felt staff were kind and caring. A person said, “I feel safe with staff, I trust them completely.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks posed to people were not always assessed and people did not always have an associated care plan to guide staff about how to safely support people. For example, people lacked risk assessments and care plans in relation to epilepsy, pressure care and mobility. Whilst we found staff had contacted emergency services on some occasions following people falling, there were several occasions of staff completing their own observations and assisting people from the floor. This is not in line with current legislation and best practice guidance. We also found staff had attempted to move people following a suspected injury. We asked the provider to report this incident to the local authority following our inspection. Following our inspection, the provider assured us steps had been taken to ensure staff followed the correct procedures following falls.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People were supported by staff in their own homes. People told us staff supported them safely. Equipment was in place to help keep people safe, such as lifting equipment, mobility equipment, sensor mats, and emergency pendants. Risk assessments were undertaken of people's home environments to ensure people and staff were aware of any potential hazards. A person said, “They (staff) leave things as they find them. If it’s night-time, they shut the door.”

The provider did not always make sure there were enough qualified, skilled and experienced staff. People told us staff mostly arrived on time, however we could not be assured people received call times in line with their allocations because several staff were found to be logged in and out of calls away from people's property. Staff had not always received training to carry out their roles effectively. There was a lack of training in relation to diabetes, epilepsy and pressure care. We also found some staff were overdue mandatory refresher training. However, people told us staff had the skills and knowledge to support them. Staff were recruited safely and all pre-employment checks were in place. Staff received regular supervisions and attended team meetings. A staff member said, “I have an appraisal every 12 months, and supervisions, also team meetings. The managers are approachable and fair to all staff. Staff morale is great.” People and relatives told us staff were kind and responded to their needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly. Systems and policies were in place to protect people from the risk of infection. Audits and spot checks on staff practice were undertaken. People told us staff kept their homes clean and tidy. Staff had received training and understood their responsibilities about infection prevention and control. Staff told us they had access to personal protective equipment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We could not be assured people received their medicines as prescribed, due to gaps in medicines administration records (MARs). Whilst we found most records were completed, we identified gaps relating to a night-time medicine for 1 person, we also found 1 person had several gaps in their MAR with no reasons recorded. People who received 'as required' medicines, did not have any specific protocols to guide staff about how and when these should be given. Staff were trained prior to administering medicines to people; however, some staff were overdue refresher training. Staff had received regular medicines competency checks and policies and auditing systems were in place; however, these had failed to identify gaps in records.