Whiteheart Health 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 inspection since the service was registered. 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.

This service scored 59 (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. Lessons were not always learnt to continually identify and embed good practice. Staff completed incident forms when necessary, which had been reviewed by the registered manager. Although there was evidence of individual actions taken in respect of the person involved in the incident, the provider did not have a system to apply this learning to the support provided to other people using the service. This increased the risk that other people using the service would be exposed to similar incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. People told us they received good support to set up their care service, with good communication, for example when they came out of hospital. People were supported to access services from a range of professionals. Assessments completed when people started using the service included information about services they were already accessing, to ensure their support was maintained.

Staff did not always have a clear understanding of safeguarding procedures or the actions they should take if they suspected people were being abused. Whilst most staff we spoke with were clear on the actions they should take, 1 support worker was unable to tell us about the safeguarding processes or what they had learnt in their safeguarding training.

We identified 1 record indicating a person had alleged that property was missing from their home. We discussed this with the registered manager, who told us the person was “hallucinating”, and no property was missing.The registered manager had not followed their policy and reported this allegation to the local authority safeguarding team.

However, people told us they felt safe when staff provided care for them. We received positive feedback from professionals in the local authority safeguarding team about how the provider had worked with them to keep people safe. Records demonstrated other safeguarding concerns had been responded to appropriately, with action taken to keep people safe and report concerns to the safeguarding team and the Care Quality Commission. Safeguarding was discussed regularly in staff meetings and information had been provided to all staff on how to report any concerns or allegations of abuse.

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 always have guidance needed to support people safely. For example, 3 of the 6 people whose records we reviewed were prescribed paraffin based topical creams. None of these people had a risk management plan in place regarding the increased fire risks when using these creams. The registered manager was not aware of published guidance regarding support for people to use paraffin-based creams. One person had a catheter, and their risk management plan stated a family member provided all catheter care. However, staff regularly recorded they had provided support for the person to manage their catheter. Staff supported 1 person to withdraw money from the bank and spend cash on their behalf. There was no risk management plan in place setting out how staff should provide this support or the safeguards in place.

The provider took immediate action to address the shortfalls we identified. By the second day of the inspection risk management plans had been developed with people covering these areas and staff had been given updated guidance.

The provider did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice. Staff completed incident forms when necessary, which had been reviewed by the registered manager. Although there was evidence of individual actions taken in respect of the person involved in the incident, the provider did not have a system to apply this learning to the support provided to other people using the service. This increased the risk that other people using the service would be exposed to similar incidents.

The provider did not always make sure staff had completed relevant training for the support they were providing or that all recruitment checks had been completed before staff started working at the service.

Staff supporting people with catheters and epilepsy had not completed any training on how to provide this support safely. This, along with the lack of risk management plans, increased the risk that people would receive unsafe care. The registered manager took action to provide training for key staff by the second day of the inspection. Training for all other staff had been scheduled.

Recruitment checks did not always include a full employment history of the staff member. We discussed this with the registered manager, who was not aware of the need to obtain a full employment history before staff started work. The registered manager had obtained this information by the second day of the inspection. Other required recruitment checks had been completed before staff started work, including a criminal record check, references from previous employers and confirmation staff had the right to work in the UK.

Although we found some shortfalls in staff recruitment and training, people told us staff had the right skills and knowledge to meet their needs. Staff said they had realistic work schedules and received regular supervision and an annual appraisal.

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 followed good infection control practice when providing care. Staff had completed infection prevention and control training and told us they had access to all the protective equipment they needed.

The provider did not always make sure that medicine management support was safe. Medicine administration records (MAR) did not always contain the prescribing instructions from the GP. For example, lack of information about the dose of the medicine, lack of information about allergies to certain medicines, and lack of details about how the medicine should be taken. The MAR had not always been completed by staff. One person had a care note stating they had been supported to take their medicines, but the MAR had been left blank for that time. This person also had unexplained gaps in their MAR on 5 occasions during June 2025. The missing information meant it was not possible for the provider to demonstrate people had been supported to take their medicine in line with prescribing instructions.

Although we found shortfalls in the records, people told us they were happy with the support they received to take their medicines. Staff we spoke with said they felt confident administering medicines and had been assessed as competent by their manager.