Purple Heart Health Care

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 newly registered service. 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.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incident management, oversight and learning were limited. Staff had not always followed the provider’s incident management policy and procedure. For example, some people using the service experienced behaviours of concerns that at times required staff to use restrictive physical intervention (RPI). Staff had received accredited training to use this when required, and only as a last resort. However, staff were required to complete incident and other monitoring records and to inform the registered manager without delay when RPI had been used. From reviewing 2 people’s daily care records for January 2026, we identified incidents that had not been reported as required. This meant the registered manager was unable to have effective oversight to investigate and learn from safety events. This was discussed with the registered manager who agreed to follow up immediately.

Where historic incidents had been recorded and reported, there had been no analysis by the registered manager for themes, patterns and learning. This was a missed opportunity to assess and understand people’s functional behaviour and to inform proactive support strategies. In discussion with the registered manager, they agreed this had been an oversight and improvements were required.

The provider did not always work well with people and healthcare 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.

The provider’s systems and processes for assessing people’s care and support needs before care was provided needed further development. For example, important information relating to a person’s known health care needs and risks was identified but not consistently acted upon. This meant staff did not always have clear guidance of how to manage and mitigate risks. This put people at risk of not receiving safe and consistent care.

The provider had no systems or processes in place to share important information with external professionals, such as ambulance or hospital staff. This was a concern because people were entirely reliant on others to meet all their care and support needs, and consistent, accurate information was essential to ensure their safety and continuity of care. We discussed this with the registered manager, who told us they would implement a document for staff to use to share this information when required.

Relatives confirmed they had been involved in the pre-assessment and transition process with the registered manager and external professionals.

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. They did not always 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 always share concerns quickly and appropriately.

The provider’s systems, processes, and oversight for managing incidents, including behaviours of concern, were not sufficiently robust. For example, guidance for staff of what RPI may be used as a last resort was not consistently assessed and planned for. These shortfalls increased the risk that people may not receive care and support in line with their assessed needs, potentially compromising their safety, wellbeing, and the consistency of the support provided. We discussed this with the registered manager, who agreed improvements were required and assured us they would take immediate action to address this.

The provider had not shared safeguarding information with people who used the service or with their relatives. This was important because people needed support to understand what safeguarding was, how they could raise concerns, and what the provider’s responsibilities were in keeping them safe from harm.

Relatives told us they were confident staff provided safe care and support. A relative said, “I have no concerns about safety at all.”

Staff received safeguarding refresher training and demonstrated an understanding of their responsibilities to protect people from abuse and avoidable harm. A staff member said, “Safeguarding means protecting individuals from abuse, neglect, and harm. My responsibility is to remain vigilant, follow safeguarding policies and report any concerns immediately.”

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.

The risk management and mitigation guidance available to staff regarding people’s known risks was insufficient. Information provided was often generic and did not reflect the specific needs, risks, or personal circumstances of the individuals being supported. For example, staff were instructed to follow an occupational therapist’s moving and handling recommendations, yet these were not recorded. Without clear, detailed, and personalised guidance, there was an increased risk of staff delivering care inconsistently and not in line with each person’s assessed needs.

Some people experienced distress and or agitation. While one person had a Positive Behaviour Support (PBS) plan in place, another did not. The registered manager said this was an oversight and agreed this was required. Overall, PBS principles were largely absent, resulting in limited focus on preventive strategies, skill development, and personalised approaches to reduce the likelihood of behaviours of concern. This increased the risk of inconsistent and reactive responses from staff, rather than proactive and person‑centred support.

Staff had received training in the use of restrictive physical intervention (RPI). However, a person’s health needs had not been assessed in relation to the potential impact of RPI, which may have affected its safe and appropriate use. This highlighted a lack of thorough assessment, monitoring, and oversight in ensuring interventions were safe and personalised to the individual.

Relatives were positive about how staff managed behaviours of concern. A relative said, “[Name] can be aggressive, staff are trained to use 'safe holds’, but they are not often used, [name] responds well to redirection/ behavioural strategies, staff know them really well, and they respond well to them.

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.

An environmental risk assessment had been completed in relation to the safety of the person and staff. However, this lacked sufficient detail and did not fully identify or address the specific risks present within the environment. Important information about potential hazards, required control measures, and staff responsibilities was missing, which meant the assessment did not provide clear guidance to ensure safety.

Where people were supported with bathing, the staff guidance did not include important information or risk‑mitigation measures, such as the requirement to check and record water temperature. This lack of detail increased the risk of unsafe practice and meant staff did not have clear instructions to ensure people were supported safely during personal care.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had safe staff recruitment procedures. These checks were completed before staff commenced, ensuring only suitable candidates with the right skills and experience were appointed. New staff received induction training, which included shadowing experienced colleagues.

Staff received ongoing training. This included required and expected training in learning disabilities and autism awareness. Staff received regular opportunities to discuss their work, training and development needs. Staff were positive about the support they received. A staff member said, “We receive helpful training which has really helped me grow in the field and become a competent carer. We receive supervision every 4 months. I can contact my manager anytime, as they are always available to help me if I need help.”

There were sufficient numbers of staff to meet people’s care and support needs. Whilst daily care records did not consistently confirm people received care from the number of staff assessed as required, this was a recording issue. Relatives confirmed people received care and support in line with their assessed needs and commissioned care package.

Relatives were positive about the staff’s competency and ability in meeting and understanding their family member’s care and support needs.

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.

Staff training records confirmed staff had completed infection prevention and control training. Staff told us they had access to personal protective equipment (PPE).

Staff spot checks were completed, which included observations and discussions with staff about infection prevention and control practices and expectations.

Relatives told us they had no concerns about infection, prevention and control practice. Relatives and staff confirmed PPE was worn and disposed of safely.

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

The registered manager told us that staff completed annual refresher training, and staff training records confirmed this. They also explained that staff competencies in the management and administration of medicines had not been completed because relatives were responsible for administering medicines to their family members. However, when we reviewed people’s daily care records dated January 2026, we found instances where staff had administered medicines. This occurred despite staff not having their competency assessed and without a medicines care plan or risk assessment in place.

We raised this with the registered manager, who took immediate action to assess staff competency. The situation demonstrated a lack of management oversight and staff accountability in ensuring that only competent staff administered medicines and appropriate guidance was in place to support safe practice.