Whispers Care Solutions Limited

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 assessment we rated this key question good. At this assessment the rating has changed to 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 people’s safe care and treatment and consent.

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 consistently implement effective systems for investigating safety events to ensure learning would take place. While leaders could describe reporting, investigating, and learning processes, these were not always carried out effectively. For example, incident forms reviewed by senior staff were not consistently thorough in identifying necessary learning or follow-up actions to mitigate risks. Some incidents and events reviewed reflected a recurring theme where key actions to mitigate future risks and improve care were overlooked. In each case, while immediate issues had been addressed to some extent (for example, reimbursing damaged items or investigating events), follow-up actions to update care plans, revise risk assessments, or provide staff guidance were not taken. This indicated missed opportunities for learning and preventing similar occurrences in the future.

Staff largely felt encouraged to report safety incidents and believed the provider promoted a culture of safety and openness. However, feedback about the response to risks, incidents, and accidents were mixed. Some staff felt responses to learning from incidents could be more robust and they could benefit from more opportunities for proactive team collaboration with input from staff that had sufficient hands-on care experience.

Despite systems for immediate actions and wellbeing checks following incident reports, these actions were not adequately recorded or reflected in senior staff reviews. This led to missed opportunities for identifying learning and implementing effective strategies. Although some incidents lacked documented learning or actions, where learning was identified, the provider utilised effective mechanisms such as regular "compliance corner" emails to share insights with staff.

The provider did not always work effectively with individuals and healthcare partners to establish and uphold safe care systems. They failed to ensure that appropriate legal processes were followed, and necessary records were maintained for some people transitioning between services or from childhood into adulthood. Although the provider collaborated closely with people, families, and healthcare partners to create care systems, their framework and approach did not adequately account for the Mental Capacity Act 2005 (MCA) and its associated code of practice.

Clear care or treatment plans were not consistently in place, and there was insufficient evidence to show that consent had always been obtained in line with relevant legislation and best practice. For example, mental capacity assessments and best interests’ decisions were not consistently in place for some people. As a result, the service struggled to demonstrate how decisions had been made in people’s best interests or how they ensured that the least restrictive options had been determined, particularly for those exposed to higher risks of harm. The legal processes related to consent, mental capacity, and best interests’ decisions were not consistently adhered to, limiting the provider’s ability to monitor and evaluate arrangements to ensure they were safe and suitable for people through transition.

The provider took steps to start addressing this issue, showing responsiveness during the assessment process by educating themselves on the MCA and applying this knowledge in discussions with healthcare partners. However, more time was needed to embed and apply this learning within the service. One professional noted that the service would benefit from additional training to enhance staff understanding of the MCA and informed consent, especially for individuals aged 16 and above.

The provider had implemented a framework to identify the requirements necessary for meeting peoples’ needs successfully. This framework guided their pre-assessment processes and was tailored to each of their areas of expertise. For example, for complex care packages, the provider's pre-assessment process included identifying shadowing periods and training needs specific to the person and their support needs. This approach enabled the provider to support consistency in care for people as they transitioned between services.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately. Leaders demonstrated an understanding of local safeguarding procedures. Staff told us they had completed safeguarding training including for children and were able to describe their responsibilities in relation to identifying and reporting concerns about abuse. Staff confirmed they knew how to raise concerns about people’s safety. There was a clear safeguarding and whistleblowing policy available with details of which agencies to contact in the event of any concern. Leaders and staff demonstrated an understanding of potential safeguarding risks to people living in their own homes. Such as risks relating to self-neglect, social isolation and cognitive decline.

The provider had an inconsistent approach to risk management and did not always ensure people’s care plans and risk assessments were kept updated with any changes to a person’s needs and emerging risks. While we found some risk assessments were person centred and clear, this was not the case for all people. Some people’s risks were not clearly assessed which impacted on how staff were able to consistently and confidently support the person to manage the risk; such as when supporting people with their money or anxiety related behaviour or when people’s needs changed. However, some staff were able to describe how they supported people to stay safe.

The provider did not always have effective systems and processes in place to ensure people’s rights were consistently upheld and protected from the risk of avoidable harm. Staff and senior leaders were clear when children were restrained for their safety it was to be least restrictive and for the least amount of time possible. Systems were in place to report any incidents where restrictive practices were used.However, staff and leaders were not able to evidence how the reactive strategies of restrictions and restraint had been identified for children and young people, or how they had determined they were the least restrictive actions to be undertaken in each person’s best interests, as they did not have the appropriate records in place. They were also not able to evidence who had been involved in identifying and agreeing the least restrictive approaches for people, how they had been determined to be in their best interests and whether there had been input from the appropriate health and social care professionals when making those decisions. The provider was not able to demonstrate nationally recognised evidence-based guidance had been used when designing people’s behaviour management plans. This meant people were at an increased risk of being subject to acts intended to control or restrain them which were not lawful, for a legitimate purpose, safe and necessary, and based in best practice.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

There were enough qualified, skilled and experienced staff, who received effective support, supervision and development to attend all care visits. They worked together well to provide safe care that met people’s individual needs. People overall told us they felt staff were trained and generally competent in meeting their support needs. Comments included, “I’ve got to know most carers who come, and they know my routine and follow it”, “All carers are competent, capable and well trained” and “They know what they are doing.”

The provider had their own internal training department, and staff were kept up to date with training. Training was available outside office hours at weekends and in the evenings. Completion rates for training, supervisions and spot checks were monitored to ensure all staff received appropriate support. Recruitment was robust and pre-employment checks were in place prior to an applicant commencing their employment. An induction was completed by all new staff members.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Records showed people received their routine medicines as prescribed, and staff were trained and regularly assessed as competent to manage medicines safely. Risk assessments relating to paraffin-based emollients were in place, and we identified an opportunity to strengthen them further to align with best practice. This was shared with the provider following the inspection, in the context of their established commitment to continuous improvement.