Unique Care Network 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 requires improvement. At this assessment the rating has remained 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 provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

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. Lessons were not always learnt to continually identify and embed good practice.

Systems for identifying, reviewing and learning from safety concerns were not always effective. Weekly medication audits failed to identify missed doses of prescribed medicines and inaccuracies in medication administration records, reducing assurance that medication errors were being effectively monitored and addressed. Monthly care plan audits also failed to identify incomplete care plans, contradictory information, and missing health-related guidance. These omissions reduced assurance that lessons were being identified and embedded to improve safety and quality of care. Although the provider responded promptly to concerns raised during the assessment and acted following identification of medication issues, governance processes had not identified these concerns prior to our visit.

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.

Care records and healthcare information were not always consistent or sufficiently detailed to support safe and coordinated care. For one person, communication needs recorded within their hospital passport, including the need for staff to use sign language and pictures, were not reflected within care plans. Information relating to a significant health condition and how this condition effected the person was absent from their medical care plan. Contradictory information regarding sleep patterns further reduced assurance staff had access to accurate information when supporting the person.

The provider had not always sought appropriate healthcare advice when concerns arose. Records showed multiple missed doses of a critical medicine however, there was no evidence medical advice had been obtained regarding the potential impact of missed doses or alternative administration arrangements.

The provider did not always work well with people and healthcare partners to understand and manage risks affecting people's safety and wellbeing. Systems intended to protect people from avoidable harm were not always effective. We identified gaps in risk assessments, care planning and medicines management, including the absence of guidance relating to missed critical medication, incomplete health information, inaccurate PRN medication protocols and fire risks associated with prescribed emollient creams which had not been fully assessed. These issues reduced assurance risks were consistently identified, reviewed and managed to keep people safe. However, where people lacked capacity to make specific decisions, the service was working in line with the principles of the Mental Capacity Act 2005.

The provider did not always work well with people to understand and manage risks. Whilst there was evidence that people and their relatives were involved in care and support planning, risk management processes were not always effective or reflective of people's current needs. We found that risk assessments did not always accurately identify and assess known risks, including those associated with prescribed emollient creams carrying a flammability risk. Care records and risk assessments lacked sufficient detail in some areas, and important information relating to people's health conditions and support needs was not always recorded consistently. In addition, there was no evidence that appropriate professional advice had been sought following repeated missed doses of prescribed medication, despite the potential risks to the person's health. These issues reduced assurance that risks were always identified, reviewed and managed in partnership with people to support their safety and wellbeing.

The provider did not always detect and control potential risks in the care environment. We found prescribed skin care products carrying flammability warnings had not been incorporated into fire risk assessments. This meant staff may not have considered risks associated with contaminated clothing, bedding or proximity to ignition sources. Inaccurate information within fire safety documentation reduced assurance environmental risks were being identified and managed appropriately.

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

The provider operated recruitment procedures designed to ensure suitable staff were employed, and records demonstrated recruitment processes had been followed.

Although previous conditions included staff training and competency, the evidence we reviewed at this assessment showed staff had completed training relevant to their roles and could describe how they supported people safely.

Relatives spoke positively about the staff team and the support provided. During the assessment, we observed caring, respectful and positive interactions between staff and people using the service.

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 told us gloves and aprons were readily available when needed and we observed Personal Protective Equipment (PPE) was disposed of appropriately after use. Staff did not raise any concerns about the availability of PPE. The provider had appropriate infection prevention and control procedures in place, and staff demonstrated a clear understanding of their responsibilities in reducing the risk of cross-contamination. Staff consistently followed infection prevention and control practices when supporting people. During our visits, we found the homes to be clean and well maintained, with appropriate standards of cleanliness observed throughout. We also observed staff following good infection control practices, helping to promote a safe and hygienic environment for people receiving care and support.

The provider did not always make sure medicines and treatments were safe and met people's needs, capacities and preferences.

Medicines were not always managed safely. One person's care record did not explain the purpose of prescribed critical medicine or the health condition being treated. Multiple doses had been missed, records were not completed consistently, and audits had failed to identify omissions. There was no documented evidence medical advice had been sought following missed doses, and no guidance was available to support staff in managing medication omissions. These concerns increased the risk of unsafe medicines management and avoidable harm.

We also identified concerns regarding medication documentation and governance. PRN protocols contained inaccuracies, omissions and copied information, including incorrect indications and dosing information. Although the provider took prompt action after concerns were raised and obtained confirmation from the pharmacy regarding administration instructions, these issues reduced assurance that medicines were consistently managed, recorded and reviewed safely.