Wisdom Support Services 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 that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of the legal regulations relating to safeguarding and fit and proper persons.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff listened to concerns about safety and investigated when required, ensuring safety events were appropriately reported and managed. Staff meetings were used to share lessons learnt and best practice to drive improvements and embed these within the service. One staff member told us, “We have learning shared in handovers and from our immediate line managers.” Another said, “We do discuss learning from incidents in meetings."

The provider had effective systems to ensure continuity of care. Staff worked with people and health and social care partners to establish and maintain safe systems of care, in which safety was managed and monitored. Continuity of care for people was maintained through ensuring staff support teams had access to all appropriate information about people’s needs.

We saw that people had a ‘hospital passport’ in place. A ‘hospital passport’ includes important information for other health professionals about the person and their health needs and preferences, should the person be admitted to hospital.

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. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. The provider had only one safeguarding concern since the last inspection and had reported this to the local authority. However, the provider had not notified CQC of a recent safeguarding concern and were not aware of this omission or able to explain the reason for it.

During the onsite visit, we observed poor restrictive practice in relation to food. Records showed the service had consulted people with legal authority or responsibility to ensure decisions were made within the requirements of the Mental Capacity Act 2005. However, due to our observations during the onsite visit, we could not be assured restrictions were being applied appropriately to ensure people's rights and dignity were always protected and there had been consideration of less restrictive alternatives.

We raised this the registered manager who following the assessment sent an action plan advising they would review all restrictions in place to ensure least restrictive options were considered and this was clearly documented in people’s records.

We will follow this up at the next inspection.

There were systems in place to ensure oversight of accidents and incidents and records showed that appropriate actions were taken by staff where required.

There were safeguarding policies and procedures in place and staff were trained to recognise and respond to concerns, potential abuse and harm. Staff we spoke with could describe the different types of abuse and reporting procedures if they had any concerns. They told us they were confident any concerns would be managed appropriately. One member of staff commented, “I would report it straightaway to my manager, I know they would act” and “I would escalate to my line manager, and I would report to safeguarding team/CQC.”

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 supportive and enabled people to do the things that mattered to them. For example, we looked at nutrition risk assessments for 2 people and saw there was poor management around food as people did not have the autonomy to eat what they wanted when they wanted to.

For one person we saw their risk assessment documented that the person may try and eat ‘food that is off or contaminated. Staff to use distraction techniques.’ However, the risks from eating food no suitable for consumption had not been mitigated and there was no guidance for staff on the distraction techniques they should use. For the second person, we saw their food risk assessment documented food should be locked away. No food should be left in the kitchen, except for healthy food, e.g. carrots, celery and apples should be cut up and left in boxes.

Risks had been assessed and managed associated in relation to personal care, medicines, nutrition, choking, fire safety, learning disability, self-harm, behaviours of distress, swimming, and accessing the community.

The provider did not always identify or manage potential risks within the care environment. In the 2 supported living services we visited, we observed a lack of fire extinguishers and fire doors. We raised this with the registered manager and made a referral to the London Fire Brigade to conduct an independent fire risk assessment. The registered manager told us they would also seek guidance from the London Fire Brigade and ensure any recommendations would be implemented.

Individual risk assessments and suitable personal evacuation plans were in place to outline the support people needed to evacuate in the event of an emergency. Fire safety and equipment checks were completed and staff had received fire training.

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. As a result, there was a risk that people could receive care from staff whose suitability and good character had not been fully established prior to commencing employment.

During our review of 7 staff files, we found that Disclosure and Barring Service (DBS) checks for 1 staff member had not been completed until after they had started work. DBS checks are essential as they provide information about convictions and cautions held on the police national computer and support safer recruitment decisions. Providers are required to demonstrate clear reasons where a full DBS check has not been obtained prior to appointment and to show that any associated risks have been appropriately assessed.

Application forms for 2 staff members were incomplete, with unexplained gaps in education or employment history. We were not assured that references were consistently reliable, as references for 2 staff members were not verified by the provider The provider did not use structured interview records to evidence the questions asked or to demonstrate how candidates had been assessed for suitability and competence for their roles.

We raised these concerns with the registered manager. Following the assessment, they provided an action plan confirming that recruitment practices and all staff files would be reviewed to identify and address any shortfalls.

Staff had undertaken a range of training, including safeguarding, medicines management, autism awareness, epilepsy awareness, food hygiene, fire safety, and infection control. However, the training matrix provided was undated, which meant we could not be assured that training was up to date or that refresher training had been completed within required timescales. After the inspection, the registered manager provided a copy of a training tracker which showed and monitored the dates staff had completed training and highlighted when refresher training was due.

Staff felt supported and had regular supervision and appraisal.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control policies and procedures were in place and staff had received infection control training. However, during our visit to 1 home we found that, while the premises were generally clean, the kitchen area was not maintained to an appropriate standard of hygiene.

Infection control risks were not always been assessed and there was a lack of guidance for staff in relation to maintain a hygienic environment.

We observed an old and rusted microwave that was being used to store and heat food, along with worn and unhygienic wooden chopping boards. Kitchen appliances such as cookers, extractor fan, washing machine and tumble dryer and kitchen cupboards were dirty and unhygienic. We observed that high level cleaning including dusting and wiping had not been carried out for some time. These issues placed the person at risk of infection and avoidable harm.

Risks around infection control had not been assessed and management plans were not in place to mitigate and manage these risks.

We raised these concerns with the registered manager. Following the assessment, they provided an action plan confirming the landlord would be contacted to address the extractor fan filter.

There was appropriate personal protective equipment (PPE) available for staff to use when delivering personal care. Both staff and relatives confirmed that staff used PPE when supporting people.

Following the assessment, an action plan was provided by the registered manager, confirming that all relevant infection control and fire risk assessments would be reviewed and updated by end of January 2026. This will be followed up at the next assessment.

Overall, medicines were managed safely. However, during a visit to 1 person’s home, we found out-of-date prescribed ear drops and an out-of-date flammable emollient stored in an unsecured kitchen cupboard. We raised this concern with staff, and the items were removed immediately.

Following the assessment, the registered manager provided an action plan confirming that all medicines and topical creams would be stored in lockable cupboards, in line with the provider’s medicines management protocol.

We also found that competency assessments for the administration of medicines had not been completed for 3 of the 7 staff files reviewed. The registered manager advised the staff had not yet been assessed as they were currently not administering medicines to people using the service.

We found that people received their medicines safely and as prescribed. Other medicines were stored securely in locked cabinets, and Medication Administration Records (MARs) were completed accurately. ‘As required’ (PRN) medicines protocols were in place and provided staff with clear guidance on when PRN medicines should be offered and administered, including dosage and circumstances for use.