Hearts of Care Agency

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. This key question has been rated Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to safeguarding, safe care and treatment and staffing.

The provider’s safeguarding processes were not effective in recognising and acting on safeguarding concerns. We found safeguarding concerns which had not been escalated and reported to the relevant authorities. Risks to people were not always effectively identified, assessed and there was lack of robust guidance for staff on how to support people around their specific risks related to behavioural support needs, safeguarding or environments in which care was provided. The provider did not have effective systems and processes in place to ensure staff competencies were appropriately checked and monitored, so staff had the appropriate skills and knowledge to provide safe and good quality care to people.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider did not have effective processes in place to identify lessons learnt from things that went wrong or from people’s feedback. For example, not all lessons learnt, and improvements needed in the service were identified as the governance processes were inadequate. The manager and director told us the service recorded accident and incidents and any safeguarding allegations on an electronic system but there was no regular oversight and analysis of incidents to prevent reoccurrence and mitigate risk. This meant opportunities to learn lessons to improve people’s safety and care experience could be missed. Not all lessons learnt around safeguarding people with a learning disability, were identified and actioned at the time of the assessment. The director and the manager were unable to explain how they ensured risks to people were not overlooked and that all concerns raised were appropriately reported and investigated.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

While the people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. The provider did not ensure safe and effective management of changes in people’s care needs and effective communication with partners. This impacted people's safety.

The provider’s systems and processes did not ensure they worked effectively with partners, including social services and healthcare professionals to adjust people’s care when people’s needs have changed. We were told about a person who had frequent seizure episodes, staff told us they would listen to what the young person’s mother said in relation to their care needs but they did not formally document this information. This was a missed opportunity to guide and inform the staff that supported this person and potentially identify themes and trends. We were told by staff that the last meeting with a social worker was in 2024. There was no system in place to monitor peoples changing care needs.

Although the provider stated they delivered the care that was needed, there was limited assurance on how they worked with other partners involved in people’s care to ensure appropriate care reviews had happened and that people’s information was up to date. This put people at risk of not receiving appropriate care and support to meet their needs.

While the people and relatives we spoke to expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. Staff had received safeguarding training but did not understand how to put their training into practice. We found examples of where staff had failed to recognise safeguarding concerns and had not taken appropriate action such as reporting incidents to the local authority and the CQC. This meant that incidents had not been effectively investigated, and action taken to keep people safe.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

The director and manager had limited understanding of their safeguarding responsibilities. At the time of our inspection visit the manager had not completed the provider’s safeguarding training.

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.

While the people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. The provider failed to recognise, review and mitigate risks to people’s complex health conditions and personal care needs. This impacted on people’s safety.

The director and manager did not always recognise the risks involved in people’s care and the importance of assessing and addressing them to protect people which put people at risk. For example, they did not recognise safeguarding risks for one person and could not explain clearly how they were addressing these risks in the support they provided.

Staff told us they had access to people’s care plans, but these did not include clear and robust guidance on how to support people around their individual risks. For example, the risks relating to how a person’s challenging behavior was managed were not addressed. The risk assessment did not include clear guidance for staff on how to mitigate the risks when supporting the person. This put the person at risk of receiving poor care and avoidable harm. In this example it also put the wider public at risk.

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.

Risk assessments for the use of specialist equipment were not detailed. For example, when a person required a hoist to be able to transfer, the size of sling to be used was not recorded. For 1 person the care plan recorded an action for staff as ‘Check the capacity of the sling and make sure it is right size for [person]’. The care plan did not record what was the right size. This placed people at risk of receiving unsafe care.

Risk assessments did not always fully explore the individual risk such as access to hazardous substances when the service was supporting vulnerable people including children.

The provider did not make sure staff were sufficiently qualified, skilled and experienced. They did not always make sure staff received an effective induction, ongoing supervision and development. While the people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. Staff also told us they were happy with the support they received.

The provider’s training matrix was broad and generic containing 55 topics staff completed on-line. Staff completed a large number of modules in 1 day. For example, 1 member of staff completed 16 modules in a day. Leaders did not have appropriate assurance that staff understood the training they had completed as the Director told us that there was no formal check on staff understanding of each module. Some training was provided face to face on site at the office location, for example basic life support training.

There was no record of any direct observations of practice or competencies assessed by management during new staff members induction period. Most training was undertaken online with only manual handling being practical.

Staff supervision records were not fully completed and did not demonstrate how staff were supported to professionally develop.

The provider had not assessed and managed risks where the service provided support in people’s homes. For example, they had not assessed the risk to children from hazardous substances such as bleach.

The provider assessed and managed the risk of infection. People and their relatives told us staff adhered to good infection prevention and control (IPC) and supported them to maintain a hygienic home environment. One relative said, “Yes, they wear PPE. Some is kept at our home.”

Staff we spoke with had access to personal protective equipment they needed to follow good IPC practice and completed online training in IPC.

The provider ensured staff were able to adhere to good IPC practice and had access to required PPE. There was an infection prevention and control policy in place. However, the provider’s governance systems did not effectively address IPC as an area for quality and safety monitoring as there were no IPC audits or regular spot checks of staff practice.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The service supported a limited number of people with their medicines. Records we saw demonstrated appropriate recording of administration. The manager told us that medicines administration was recorded and audited on the electronic system.