Tigheaven Ltd

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• 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 inadequate. 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.

We found the provider to be in breach of 3 legal regulations in relation to safe care and treatment, staffing and recruitment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Effective systems and processes were not in place to ensure incidents were managed effectively at the service. There were no accident and incident files in place to ensure incidents were responded to and monitored appropriately. There were no system in place to analyse incidents to identify any themes and lessons learnt and share any learning from incidents with staff to improve safety at the service.

For example, an incident form was completed for an incident in January 2025 in which staff and the registered manager responded to and sought medical attention. The incident occurred in January; however a reassessment of the person’s needs was not done until March 2025. There were no lessons learnt identified to show learning from this incident had been disseminated to staff to minimise risks in the future.

The registered manager was not always aware of their regulatory responsibilities to notify the CQC and submission of statutory notifications of any significant events at the service. We spoke to the registered manager who told us they would ensure CQC and relevant healthcare professionals were notified of any incidents when they occurred.

Assessments of people’s needs were carried out prior to people joining the service to ensure their care needs could be met. However, there were no care plans put in place as result of the assessments to ensure care and support was planned in accordance with people’s needs and potential risks were identified and managed appropriately to maintain people’s safety and continuity of care.

People and relatives told us if people had been in hospital and were returning home, there had been effective transitions from hospital to people’s homes. A person told us, “I’ve been into hospital twice in the last week and the carers are always in place, and they adjust really quickly to the follow on instructions.” Another person told us, “I was in hospital and when they discharged me, I had the same carers back the following day – very good.”

People and relatives told us they felt safe using the service. A person told us, “Yes I am safe with the care, I know what I need and the carers do that. It’s all good at the moment.” A relative told us, “[Person] is happy and safe and does a lot for themselves too.” Another relative told us, “[Person] is really safe with them, I’m confident [person] is being well looked after.”

Records showed where there were safeguarding concerns, the service had worked with the local safeguarding teams to mitigate further risk to people. However, there was no safeguarding file in place to ensure safeguarding concerns were recorded and there was effective oversight and learning of concerns raised to help protect people from abuse.

Staff had completed safeguarding training and there were safeguarding and whistleblowing policies in place to report potential abuse. A healthcare professional told us, “There are currently no outstanding complaints or reports regarding the provider. When concerns around care and support needs have been identified in the past, these were communicated clearly and appropriately to the local authority and responded to promptly and professionally.”

Effective systems and processes were not in place to identify and assess risks to health, safety and welfare of people who use the service. Risks to people were not always adequately assessed and there was limited information in place for staff to ensure risks were mitigated.

For example, 7 people due to their mobility, required the use of mobility aids such as a wheelchair, zimmer frame, hoist, sliding board and sliding sheets. There were no risk assessments in place and guidance detailing the risks and appropriate moving and handling techniques required by staff to ensure this was done safely and to protect and mitigate the risk of falls and unsafe transfers.

2 people required support with catheter, stoma care and a feeding tube. There was no risk assessments in place providing guidance to staff on the potential risks involved and how this should be done and managed safely and to ensure staff were working consistently against clear guidelines.

Records for a third person stated they had a pressure sore and needed support with the application of a cream. There was no risk assessment in place detailing guidance for staff to prevent and minimise the risk of further pressure sores. There were also no further details of the creams and areas to be applied and actions for staff to take, should there be any issues regarding skin integrity.

A fourth person was at risk of neglect in relation to their diet, hygiene and appearance. There was no risk assessment in place detailing the risks and the support required by staff to help mitigate self-neglect in these areas.

When speaking to people and relatives, some relatives told us improvement was needed to keep people safe from harm. A relative told us, “They [staff] are not well trained. [Person] needs hoisting to get out of bed and that does not always go well, and they are not comfortable. [Person] wants to be in a wheelchair and get out but isn’t confident with some of the carers. This means [person] mostly stays in bed because they are fearful of the hoisting and worried about being dropped. Many of the carers are clearly nervous about the hoisting, some are excellent.” Another relative told us, “Training on hoists could be improved sometimes the carers standards are not good.” A third relative told us, “You can see lots of them are learning, they are very inexperienced but do come with someone experienced. A couple of times we have had a third one watching and learning. There were some concerns over hoisting, the carers were not using the brakes on the hoist.”

Environmental risk assessments had not been undertaken in people’s homes to ensure risks within the environment were assessed and monitored to maintain people’s safety and ensure people received their care in a safe environment. This meant key risks around the home were not addressed or mitigated, such as fire.

Effective recruitment systems and processes were not in place to ensure staff were of good character. Some pre employment checks were not completed satisfactorily before staff were employed.

We reviewed 4 staff files. The applications forms for 2 staff did not detail any dates for their education and employment history. For another staff member, there was an unexplained gap between 2015 and 2022 which had not been explored by the provider.

The interview forms used were questions completed by staff and no further detail to show how staff had been assessed and confirmation of suitability and competence for the roles applied for.

For two staff members, the service failed to ensure that 2 adequate references were obtained before staff commenced work. For example, 1 staff member commenced work in November 2024, however 2 references were obtained in February 2025. The references were also not adequate as 1 reference was from a family member and the other reference was not completed.

For another staff member, their interview form had no date, but they started their training in December 2023. However, references were provided by 2 family members in January 2024. A professional reference was obtained; however, this was neither dated nor signed. There were no reasons recorded as to why adequate references could not be obtained by the provider and potential risks assessed.

The DBS checks used for 2 staff were undertaken by their previous employers. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. Providers must be able to demonstrate sound reasons for not obtaining a full DBS check before a person takes up post and also demonstrate they have assessed any potential risk. For both staff members, there were no reasons recorded as to why a full DBS check could not be obtained by the provider and potential risks assessed.

Effective recruitment systems and processes were not in place to ensure staff were effectively deployed to meet people’s needs at all times. We received mixed feedback in relation to timekeeping. Most people and relatives told us staff were on time and there were no missed visits. One person told us, “They [staff] never rush me, we have plenty of time” Another person told us, “I have two ladies I know well, and they phone if they are going to be late.” A relative told us, “We have 3 or 4 different carers in a week. I told them to let me know who is coming and if there is a change then they will call me or [person] gets anxious. If a carer is going to be on holiday they call and let me know.”

However, two family members told us, “They [carers] are not always on time and sometimes they call, they aren’t rushed and we haven’t had any missed calls” and “Some carers are more efficient than others. So this morning in the time allocated, [person] was half washed, half medicated and fed. We have lots of different carers and there is not enough consistency.”

The service was using an electronic call monitoring system (ECM) to record staff attendance times to ensure people received their care visits as planned. However, the management and oversight of the system was not effective. We found discrepancies with the call times recorded. Therefore, we could not be assured people received their care in accordance with their needs.

We analysed the ECM data and found 62% of calls were on time. However, 38% were more than 15 minutes late and 13% were more than 45 minutes late. 14% of calls were short calls. A short call is when less than half the planned time is delivered. Records also showed 131 unlogged calls.

We also reviewed the daily notes completed by staff after each call and found further discrepancies. For example, for 1 person on the 30 April 2025, the call duration logged was 16 minutes for a 30 minute call. For another person, on the 04 May 2025, the call duration logged was 7 minutes for a 2-hour call.

Records also showed people received their calls at different times. For example, on the 2 May 2025 the person’s lunchtime call was between 13:49pm and 14:24pm, however on the 03 May 2025, their lunchtime call was 12:40pm and 13:18pm. For another person, their morning calls from the 03 May to 05 May 2025 were logged as 06:03am, 07:58am and 08:57am. This meant people did not receive their care as planned.

People were protected from the spread of infection. Staff had received infection control training and implemented safe infection control practices. People told us staff always wore personal protective equipment (PPE) when supporting them with personal care. Staff had received infection control training. One person told us, “Yes they have gloves for personal care and wash their hands.” Another person told us, “They [staff] have gloves and aprons and sometimes masks and they wear a t-shirt and have a lanyard with their ID.”

Effective systems and processes were not in place to ensure people received their medicines safely. Medicines records did not accurately reflect the support people received. Therefore, we cannot be assured that people received their medicines as prescribed.

There were no medicine administration records (MAR) available during the onsite assessment and were sent to us after the onsite assessment to review. The registered manager told us that all MAR records were stored in people’s homes.

We reviewed the MAR sheets for 6 people which were sent to us after the onsite assessment. For one person, the MAR sheet showed 5 unexplained gaps.

Another person required the use of an inhaler four times a day, however the MAR sheet showed this was only administered two times a day and not four times as instructed.

The MAR sheets for 3 people showed codes for refusing some medicines were recorded. However, there were no further details recorded as to the reasons why the medicines were refused and actions taken in response.

There was no information in people’s care plans on how they should be supported with their medicines. Statements such as ‘level 3 administer prescribed medications’ were used with no further guidance for staff on how this should be done.

There were no medicines audits carried out to ensure any shortfalls were identified and followed up. The registered manager told us they would check the MAR sheets when visiting people’s homes, however there was no formal auditing process which recorded this and provided effective oversight of the safe management of people’s medicines.

Staff had received medicines training, and a medicines policy was in place. However, staff had not undertaken medicines competency assessments to ensure they were competent and administered medicines safely.