Unisus Group 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 the legal regulation in relation to Regulation 12, Safe Care and Treatment. The provider did not always ensure persons providing care had the necessary skills, competence and experience to do so safely.

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 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.

There were systems in place to record incidents and accidents; however, these were not always reviewed effectively to identify patterns, trends or recurring themes.

Relatives reported that they had raised concerns or complaints with the provider but described mixed responses. While some issues were addressed promptly, there was a shared view that actions taken were not always consistent or sustained over time. One relative described that, following concerns they had raised about their loved one’s care, the provider agreed to improve continuity through consistent staffing. However, this was not sustained, as a carer attended who was unfamiliar with their loved one’s needs. They said, “This has happened on numerous occasions, and the office staff are ignoring my calls and emails.”

The provider showed an understanding of their duty of candour. Policies were in place which outlined the requirement to be open and honest with people and their relatives when incidents occurred, including offering an apology and providing information about actions taken.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.The provider had systems in place to promote continuity of care, including during transitions between services. However, these did not always result in consistent continuity once people started using the service.

People’s needs were assessed prior to receiving the service, and this information was used to develop person centred care plans. Risk assessments were also in place to minimise potential risks and ensure people received appropriate and safe care.

The service worked with other health and social care providers to make sure information was shared. One professional told us, “Unisus complete an assessment prior to starting care, and they do request information when new needs arise.”

Staff spoke positively about working with other health and social care professionals. A staff member said, “We work in partnership with other healthcare professionals, including GPs, district nurses, and specialist services, to ensure people receive appropriate and timely support. This multi-disciplinary approach helps us to meet individuals’ needs effectively and promote their overall health and wellbeing.”

People did not always feel safe with the support they received. People’s experiences of safety were variable and largely dependent on the consistency and competence of staff. Many people using the service, along with their relatives, reported that safety was closely linked to staff experience, continuity, and familiarity with individual needs. Those receiving support from regular, well-trained carers felt more secure, as staff understood how to manage mobility, transfers, and medical needs, remained attentive to changes in health, and communicated effectively with individuals, their relatives, and the office.

One person said their relative felt safe because “They’ve been with them for a while and has the same carers.” Another relative expressed significant safety concerns, describing multiple incidents where staff were unable to safely manage care and provide appropriate support. They told us, “We have had so many different carers, lots of them [relative] doesn't feel safe with.”

Staff had received safeguarding training and demonstrated an understanding of their responsibilities to protect people from abuse and avoidable harm. Staff told us they felt confident to raise safeguarding concerns and were assured that these would be taken seriously and acted upon appropriately by managers. One staff member said, “Yes I would, if I had any concerns regarding safeguarding, I would raise these concerns with my Quality and Compliance Manager, he would then file a safeguarding report or similarly he would show me how to do it so that I could do it myself.”

The provider was working in line with the principles of the Mental Capacity Act (2005). People were supported to make their own decisions wherever possible, and capacity assessments were carried out when needed. Staff demonstrated a good understanding of the Act and how to apply its principles in practice.

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.

Although the provider had processes in place to manage risk, people’s experiences did not always reflect these systems. People did not always feel safe with the service they received. One relative told us, “New staff are overwhelmed by [Relative’s] complex needs, leading to distress and unsafe situations.”

Risk assessments were in place to support individuals to maintain as much independence as possible. Staff were able to clearly explain how they balanced promoting independence with ensuring people’s safety and wellbeing. A staff member said, “We support individuals with positive risk taking by assessing dangers and providing person centred care we focus on strengths rather than restrictions and encourage safe risk taking with our clients letting them choose safe options.” However, people and their relatives told us that their preferences for specific carers, visit times, and established routines were not always respected. This inconsistency created situations where assessed risks were not consistently managed and people’s independence was not fully promoted particularly when unfamiliar staff did not know people’s usual support needs or preferred ways of working.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

A health and safety section within people’s care plans provided guidance on the safe use of equipment. External and internal environmental risk assessments were in place to support staff to access people’s homes safely and deliver care.

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.

Although the provider had processes in place to support staff training and supervision, these were not always effective in practice. Training records showed that required training had not been undertaken by all staff. The registered manager acknowledged these gaps and confirmed that actions were being taken to address them. People’s experiences indicated that staff were not consistently trained or supported to meet their individual needs, which contributed to variability in the quality and safety of care provided.

While staff received regular supervision and spot checks were undertaken, these were not consistently effective in improving practice or addressing concerns. There were numerous reports of care being delivered by new, inexperienced, or poorly supervised staff. People and their relatives raised concerns about falls, unsafe handling, missed visits, and a lack of understanding of individuals’ medical or mobility needs. This led to feelings of stress and anxiety, particularly where relatives had needed to intervene to prevent potential harm.

People also reported that their safety was further compromised by inconsistent staffing and late visits, which resulted in missed meals, delays in medication, and, at times, unsafe practices during personal care. For example, a relative described how staff did not fully understand their loved one’s mobility needs, which resulted in an incident that led to a hospital admission.

The provider followed robust recruitment practices to make sure all staff were suitable to work with vulnerable people. Disclosure and Barring Service (DBS) checks were carried out. These provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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.

The provider had systems in place to assess and manage the risk of infection, in line with current national guidance. Policies and procedures were in place, and staff received training in the prevention and control of infection. Unannounced spot checks were carried out by the registered manager and office staff to ensure that appropriate personal protective equipment was being used and that staff were following correct hand hygiene practices.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had processes in place to support the safe administration and management of medicines. Regular audits were undertaken, and people were supported, where appropriate, to manage their own medicines safely.

Staff completed training and received a competency assessment for the safe handling of medicines before being permitted to administer medicines to people.