Ranger Home Care Ltd – Main Office

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 safe care and treatment, safeguarding and fit and proper persons employed.

This service scored 41 (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.

We found the provider did not maintain clear incident, safeguarding and complaints records to ensure they could monitor this information and identify themes or trends to drive improvement and learning. Although incidents were recorded on individual care records, this did not ensure wider learning was taken and applied to other people using the service. We reviewed team meeting minutes and found any identified learning outcomes from concerns, complaints or incidents were not regularly discussed as a team to ensure all staff were informed and aware of learning outcomes.

The provider did not evidence they completed regular audits for quality assurance and learning. This demonstrated a lack of robust processes in place to learn from incidents or concerns and drive improvement.The registered manager told us, “[The] process of reflection is really important. It’s about looking at what can we do differently, being innovative. I am proud we still look at new systems. We change[d] our training.”
 

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.

Staff were not always provided with full information about people’s care and treatment. For example, not all information from other professionals’ assessments of people’s needs was clearly and consistently recorded for staff. This meant there was a risk people’s care and treatment were not delivered in line with their assessed needs. For example, one person’s care plan stated they were currently detained under S3 of the Mental health Act. We requested additional information from the provider as the care plan did not state if the person was supported by a social worker, if they were currently on a section and any details of a mental health nurse supporting the person. The provider did not demonstrate any supporting evidence of this.

The provider had an on-call system in place to support staff communication across the service at any time.

The registered manager told us about the process of meeting people before agreeing care and establishing care plans. The registered manager told us, “I have now changed this [process] to a ‘meet and greet’. We talk about the service, then [people] can decide if they want to go with Ranger. The most important thing is trust. They need to trust our process and care. Once they accept then we have an assessment and we build a care proposal. We then discuss what sort of person they would like, what their care needs are. We build the care plan straight away through conversation, so there is no assessment form anymore.”
 

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.

For example, we found 1 person had been refusing their medicine to support their mental health needs. The person’s care plan did not include detailed information about safeguarding this person if they refused their medicine, and if there was a community treatment plan in place to ensure people always received appropriate and timely support. This meant the provider was not always able to demonstrate there were robust safeguarding processes in place to protect this person.

The provider did not demonstrate they regularly monitored and reviewed the approach to, and use of, restraint and restrictive practices. For example, people with covert administration of medicines in place were not regularly reviewed to ensure that it remained the most appropriate method of medicine administration. For another person, who’s care plan stated staff could turn their wheelchair off, the service did not demonstrate they reviewed this restrictive practice to ensure this restriction was still necessary.

From staff feedback, we identified that staff had limited understanding of Mental Capacity Act (MCA) principles, including capacity assessments, best interest decision-making, and restrictive practice. This lack of staff knowledge placed people at risk of receiving care and treatment without lawful consent.

We identified that at least two people were receiving medicines covertly. For one person, care records stated that the person “wanted” to receive medicines covertly. This indicated a misunderstanding of the MCA, as a person with capacity cannot consent to covert administration; covert administration can only occur following a formal best interest decision where a person lacks capacity.

For the second person, care records stated that the GP had agreed to covert administration of medicines. However, there was no evidence of a recorded best interest decision, no evidence that the least restrictive option had been considered, and no evidence of regular review. Although a GP letter dated 2024 was provided, this did not demonstrate that covert administration was being reviewed in line with best practice, particularly when medicines were changed.

We also found that additional medicines were being crushed and administered covertly during the site visit without this being documented or reassessed. Each change in medication requires the need for covert administration to be reconsidered and a new best interest decision recorded; this had not occurred. As a result, people were at risk of receiving medicines without lawful authority, being subjected to restrictive practices without appropriate safeguards and having their rights under the Mental Capacity Act compromised.

We also identified that one person’s care plan stated they “must be supervised at all times,” which constitutes a restrictive practice. Although the care plan noted the person could request time alone, this did not demonstrate that the provider recognised this as a restriction or had applied MCA principles appropriately. There was no evidence of a best interest decision or consideration of less restrictive options to justify constant supervision.

These findings demonstrated a systemic failure to understand and apply the Mental Capacity Act, resulting in unlawful consent processes and restrictive practices that were not properly authorised, reviewed, or monitored.

People and relatives told us they felt safe with the care provided. Staff had received safeguarding training and told us they understood how to recognise potential concerns and what actions to take.
 

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.

People’s individual risks were not always captured. This meant staff providing care and treatment would not have access to important information and associated risks. For example, one person had conditions including Polydipsia, which is the medical term for excessive, persistent thirst and abnormally high fluid intake. The provider did not demonstrate detailed and clear risk management and current assessments were in place for people’s conditions. Some staff were found completing delegated tasks without evidence of the appropriate skills, competency and training in place before completing the tasks such as manual bowel evacuation. This meant people were at risk of being supported unsafely and by unsuitable staff.

We found 1 person was using emollients yet did not have a fire risk assessment in place to ensure any risk of associated harm was mitigated and managed. Some people’s risk assessments were not up to date, and we therefore could not be assured the information was accurate for people’s current needs. For example, one person required support with moving and handling, their last risk assessment was in 2022. This meant there was a potential risk this person would be unsafely and unsuitably supported as staff did not have up to date guidance available.

A person with epilepsy did not have an up to date and clear plan in place on their care record at the time of our visit in order to guide staff on how to safely and effectively support this person. This meant some people were at potential risk of avoidable harm.
 

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.

People and their families told us they felt the service was safe. People did not always have individual risk assessments in place related to their environment. Individual risks in people’s homes such as their surroundings had not always been considered to ensure staff were aware of any risks they may be presented with.

We saw the management team completed spot checks for staff in people’s homes, however there was no evidence to demonstrate how the provider maintained oversight of safe environments and identified risks. There was no audit completed to demonstrate this.
 

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The provider did not evidence all staff providing care had been appropriately competency assessed to ensure care was delivered safely and effectively. This meant people were at risk of avoidable harm and abuse due to being supported by unsuitable staff. For example, one person’s competency assessment for insulin administration was signed by a member of the management team, who was not a registered nurse and therefore did not have the appropriate certification in place to evidence they could assess this task. Insulin administration is a delegated task. Some medicines cannot be routinely administered by a care worker. For example, injections (such as insulin) or medicines administered via a feeding tube are clinical or nursing tasks. A registered nurse (RN) can delegate the administration of these medicines to a care worker. The RN must be confident that the care worker is competent to take on this task. Delegation must always be in the best interest of the person. We did not see evidence of competency assessments for tasks such as catheter care, bowel management and medicines administration for all staff we requested these for and who undertake delegated tasks .

Some tasks were delegated to staff including insulin administration, however the provider could not evidence all ‘trainers’ within the service were qualified and skilled to train other staff for specific tasks. This meant there was risk of poor practice and teaching between staff. During the inspection the provider confirmed staff did not administer insulin. However, we found several care note entries by staff to demonstrate they were administering insulin. This did not demonstrate staff only ‘assisted’ people with these specific tasks. This also demonstrated leaders within the service did not maintain safe oversight of people’s risks, care and treatment.

The registered manager did not operate effective and robust recruitment and selection procedures to ensure they employed suitable staff. We reviewed a sample of 6 recruitment records during the site visit. We found discrepancies with gathering information of full employment history and unexplained gaps, evidence from previous employments related to health and social care regarding staff conduct and verifying the reasons for leaving. Failing to obtain all the required recruitment information before allowing staff to work, placed people at potential risk of receiving care from unsuitable staff. We discussed the requirements of this regulation with the provider and sent information about this regulation after the site visit.
 

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.

We found that staff were provided with appropriate personal protective equipment (PPE) to minimise the risk of infection spreading. We also noted staff completed training for infection prevention and control.

Staff told us, “I completed infection training. I mostly wear gloves and aprons when doing personal care. There is enough PPE and this can be delivered very quickly direct to me. No concerns about hygiene.” The registered manager told us, “Care plans are really detailed how to wash and dress people. We do spot checks all days and night, for example 7am to make sure correct procedures are followed.”
 

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

Medicines administration records (MAR) were not managed or monitored effectively to ensure medicines administration was accurate and safe. For example, 1 person’s steroid was to be administered in the morning. However, their MAR chart was not signed to show that it has been administered. This meant we could not be assured people’s medicines were administered on time and in line with prescribed guidance.

When ‘as needed’ (PRN) medicines were administered, the reason and outcome of administration were not always documented in line with good practice guidance. This did not ensure effective monitoring and usage of PRN medicines.

One person was prescribed an antipsychotic medicine for ‘agitation’. The prescribing regime was for 8am, 12pm and 9pm. However, the person’s daily notes did not reflect the person was agitated. Staff frequently noted the person was sleepy and took naps after waking up for breakfast. The MAR chart demonstrated the medicine was administered twice at lunchtimes and then again around 6pm. This demonstrated unsafe spacing between doses, and the medicine was not administered according to the prescriber’s guidance. The provider failed to evidence they were aware of this concern, and the person was not over-sedated or seeking medical support to adjust dosages if dosage times were not being followed. The provider failed to demonstrate this was thoroughly investigated before suggesting this was a recording error to ensure the person was not being over-sedated and over-medicated.

Some people’s medicines were being crushed before administering. We did not see evidence of a detailed medicines care plan or clinical guidance in place to ensure staff understood how to safely crush each medicine to ensure therapeutic effectiveness was maintained. The provider failed to demonstrate they were administering medicines in line with the prescribers’ instructions.