Winners Trophy

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 registered 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 regulation in relation to safe care and treatment, need for consent, safeguarding service users from abuse and improper treatment and staffing.

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 always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not investigate or report safety events. Lessons were not always learnt to continually identify and embed good practice. For example, at the time of our site visit, there was no system in place to record collective incidents or actions taken to enable the service to monitor for any themes or trends. The registered manager told us they had not had many incidents and therefore did not have a log available but told us they would start to introduce this to their working practices going forward. One person told us they were not satisfied with the way the provider dealt with a complaint they had raised, and the registered manager told us they had not received any complaints about the service.

However, we did see evidence of when a medicine error occurred in the service, a lesson learned analysis was done and a cascade of learning was undertaken with staff during supervisions to share good practice for the future.

The provider did not always work well with people and health system 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. It was noted on review of one service user, who had a hospital passport in place to support safe transitions into hospital, it contained some relevant information such as their diagnosis, support needs and contact details but it did not contain the frequency and timings of medicine administration. Fortunately, the service user had not yet needed an admission to hospital and the provider told us they would update the hospital passport. The registered manager told us they would complete an updated assessment of people’s needs if a person had been discharged from hospital however, a relative of a person told us a new assessment of their relative’s needs had not been completed when they returned home from hospital recently. This meant staff did not have all the information they needed to support people in line with their changed needs.

However, one partner told us, “I met with [Manager] and 2 carers to go through all the information and care plans at the start of support and found it very organised and thorough, they asked lots of questions to make sure they had all the right information to support the client.”

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.

We requested a copy of the safeguarding policy for the service and found the policy had not identified all the protected characteristics outlined in the Equality Act 2010. For example, marriage and civil partnership and pregnancy and maternity were not listed as protected characteristics. The policy did not contain the named safeguarding lead and the contact details for the local authority safeguarding teams were not available. There was no process in place for leaders to monitor for trends and themes in relation to safeguarding incidents, although at the time of the inspection the service had only identified one safeguarding concern. During our inspection, we identified a safeguarding concern which staff or leaders working at the service had not identified and we made a referral to the local authority safeguarding team accordingly. The referral had since been closed down with no further action required. One staff member had not completed their annual safeguarding training by the date on the provider’s training schedule; however, the registered manager told us this was because the person was on annual leave at the time and the training would be completed when they returned to work. We also identified two staff members names had not been included within the training records and therefore it was unclear whether they had completed safeguarding training. The registered manager told us they had completed the safeguarding training and that it was an oversight that the names were not included on the training matrix. The provider did not supply us with any certificates to confirm the staff had completed the relevant training. The systems to ensure staff did not lapse on their training compliance was not effective. When speaking with staff, not all staff could describe all the different types of abuse that could occur, and one staff member was not able to explain what the Mental Capacity Act (MCA) was and how people should be supported if they lacked capacity. The registered manager did not tell us what they would do to address these concerns.

However, people and their relatives told us they felt safe and did not raise any safeguarding concerns. Staff knew how to report incidents to the registered manager, however only one incident had been identified by the service and therefore we were not assured of the effectiveness of staff reporting incidents.

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. Care plans and risk assessments did not contain adequate information to support staff to manage people’s risks safely. For example, we reviewed two care plans where service user had diagnosed conditions but there was no further information relating to the management of those conditions for staff to follow when they provided care and support. One person’s falls risk assessment did not identify how to mitigate the risk of falls in relation to medicines they were taking and did not include all the medicines the person was taking which could have resulted in a higher risk of falls. One live-in staff member regularly went on trips into the community, days out across the country and occasional trips overnight with a service user they supported. However, there were no risk assessments in place for staff to follow when undertaking these trips which meant the person and staff member were placed at risk, because information was not available to manage these risks safely. The registered manager was not aware the risk assessments needed to be in place and told us they would complete the risk assessments, but we did not see any evidence of this being completed during the time of the inspection. However, the staff member was able to tell us what they would do in an emergency in relation to the risks for the person they were supporting whilst in the community. We received mixed feedback from people in relation to their care plans and risk assessments. Some people told us they had access to care plans and risk assessments; however, some people told us they did not have access. Most people told us care plans and risk assessments had not been reviewed regularly with them, which meant care plans may not have reflected people’s current needs.The provider told us they had moved to a new care planning system which was why all the information in relation to involving people to manage risks was not available.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

An environmental risk assessment for one service user highlighted risks in relation to them smoking inside the property and stated there were smoke alarms located in the kitchen area. However, a staff member told us there were no smoke alarms or carbon monoxide monitors in that particular service user’s property. When we asked the registered manager about this, they told us fire alarms were available in the property, however, they were not able to confirm where they were located. They could not provide evidence to demonstrate a fire alarm and carbon monoxide monitor were in the property, such as a photograph, nor were they able to provide confirmation of regular checks taking place to ensure the alarms were in working order. The provider’s live in care policy stated, “To ensure Winner’s Trophy is providing safe and effective care for people using our service and is meeting our responsibilities for the health and safety of the care workers involved.” There was insufficient assurance the provider was operating in accordance with their policy, due to a lack of evidence to demonstrate appropriate alarms or monitoring systems were in place to protect the health and safety of both a service user and staff working with them.

There was a Business Continuity Plan (BCP) in place for the service, which assessed risks relating to the environment. However, the plan did not identify what initial actions should be taken in the event of an emergency. Furthermore, the plan did not address how the service would identify and prioritise service users at high risk, such as those requiring care in bed or living alone in the event of an incident. Key emergency contact details for internal and external stakeholders were also not available in the BCP. Whilst some areas of service disruption had been identified within the BCP, the relevant actions to take to manage these disruptions had not been identified. For example, disruption such as floods, heavy snow, power outage, recruitment or retention problems were noted on the BCP, but did not identify how the business control measures would manage these risks. Staff we spoke with were not aware of the BCP. Therefore, information was not available for staff to know how to manage risks and what to do in an emergency. The provider had not reported any emergencies where the BCP plan had to be initiated and therefore the plan had not been tested for effectiveness.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. One person told us they didn’t think staff had the experience to meet their relatives needs and said staff, “were not proactive, don’t go out of the remit and try different things to encourage [person] to have their needs met. Even if it’s a cup of tea and a chat to help with well-being they don’t do that.” On review of staff training records, we found two staff member details were not available and therefore it was not clear whether they had completed training relevant to their role. The registered manager told us the staff members had completed their training but did not provide any evidence of this before the inspection was completed.

The provider was not following their own supervision policy as supervisions with staff were taking place over and above the policy in relation to frequency and what was discussed in those supervisions. For example, the policy stated, “Discussions should take place on topics such as safeguarding, whistleblowing, health safety and knowledge on policies and procedures.” However, records reviewed as part of this inspection, showed these topics were not being discussed consistently with staff. The provider was also not following the supervision template outlined in the policy which stated, “The supervision record will include the date, name of the supervisor and their designation.”

The provider had not always followed their recruitment policy in relation to the way references were received and we found application forms did not have start and end dates so the provider could not explore gaps in employment history. The provider told us they would amend their application forms during the inspection.

We found one staff member was working between two roles; as a care manager and healthcare assistant, however, they did not have separate job descriptions or contract of employment. The registered manager told us, “They were a small company and therefore, the staff member would need to work both roles.” We also found one staff member’s initial interview questions did not contain any care-based questions and this person had not worked in a care related field previously but was providing care to service users at the time of the inspection. One staff member told us they did not have regular supervision and support.

However, people told us staff arrived on time, stayed for the full duration and there had not been any instances where they had been left without support. One person told us, “They have never let [person] down, they have been a little late sometimes, not often and that was because of traffic, which we totally understand.” People told us because there was only a small number of staff it meant they got the same staff regularly which helped their relatives with continuity of care. However, they raised concerns about staff sickness and how calls would be covered in the event of staff being ill. The registered manager told us they completed visits to people along with the care manager so care visits would be covered in times of sickness. They also told us they were managing the referrals into the service to ensure they had enough staff to cover the care visits. Most of the staff told us they received regular supervision, and the care manager was supportive.

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. People told us staff used personal protective equipment (PPE) when providing care and support. Staff were able to tell us about good infection control practices and had completed online training in infection control. There was an infection control policy and procedures in place.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

On review of an Electronic Medication Administration Record (eMAR) for a service user, a prescribed dose of Bumetanide was not recorded as taken over a period of 12 days during March. This was despite Bumetanide being prescribed to be taken daily. The service user’s eMAR also showed a Buprenorphine patch had not been recorded as being changed on two occasions in March 2025 despite there being instructions to do this weekly in their care plan. This meant they were at risk of not receiving their medicines as required. The registered manager told us this was a system error, and they were normally notified if a person did not get their medication. The relative of the service user told us they checked the medicines were given daily and they had not identified any missed doses. We also noted a service user’s eMAR and medicines risk assessment for 4 medicines did not have a time of day recorded as to when the required doses of medicines should be given and did not identify the frequency for these medicines. This placed them at risk of harm because relevant medicine administration information was not available in line with national guidelines for staff to follow. The provider sent us an action plan after the inspection which identified they would make the changes in the care plan, but we did not see any evidence of this being completed. Furthermore, we identified a service user was prescribed Movicol as a ‘PRN, when required’ medicine. Although the service user’s care plan stated, “clear PRN protocols in place” in relation to the use of Movicol, when we requested a copy of their PRN protocols, the provider did not submit the documentation in the time frame stipulated. This meant a person was at risk of harm because the appropriate protocols were not in place for staff to follow as per national guidelines.

The registered manager told us medicine audits were taking place but when we requested evidence of them as part of this inspection, these were not provided.

Most relatives told us people were receiving their medicines safely from staff and they had not identified any missed doses. However, one relative told us, “They are not prompting with medication and not checking if [person] has taken them.”

There was a medicines policy in place and some staff had completed some online training in relation to medicine administration/theory, however, 2 staff names were not included in the training matrix. The training matrix also showed only some staff had their medicine competency assessed within the last 12 months, in line with the provider’s policy. The registered manager told us all staff had completed their competencies but did not provide any evidence of this.