Unite Highland Care

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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

We identified 4 breaches of the legal regulations in relation to safe care and treatment, staffing, fit and proper persons employed and safeguarding. There was a lack of robust risk management which had led to harm or the risk of harm to people. Safeguarding was not managed well and people were not protected from harm. We were not confident the provider shared all of the information around the incidents and accidents that happened in the service. The management of medicine was poor and left people at risk of harm. Staff calls were poorly organised and managed. Some people received short, late or early calls. We were not assured with the information the provider gave us around call times as it did not accurately reflect when staff were with people providing care. Staff were not recruited safely. The principles of RSRCRC were not met. The registered manager referred to people with a autism and attention deficit hyperactivity disorder (ADHD) as having a ‘mental health condition’.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While some people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. When incidents occurred, the registered manager did not have processes in place to learn or reduce the risk of incidents being repeated. A relative said, “I was thinking about it (making a complaint), but I thought what's the point. I don’t think they would (address the concern).”

Incident oversight was poor and placed people at risk. We could not be assured all incidents were recorded to ensure appropriate action was taken. There was no evidence of learning from events and the registered manager was not able to provide the information we requested around incidents and accidents in a timely way, the information they did provide was not accurate or complete. The registered manager told us, ‘It has never been my intention to obstruct, delay, or hinder any inspection process. I totally apologise for it being so difficult to look at incidents.’

A learning culture was not embedded at the service. There were ineffective processes to monitor, report and improve following incidents and accidents. For example, staff told us a person fell and daily notes confirmed they had been found on the floor on numerous occasions. The providers incident overview did not log any of these events. The provider did not learn from events or incidents. For example, a person had been admitted to hospital due to constipation however, care plan information or strategies to prevent repeated incidents had not been implemented since their discharge from hospital.

While some people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. Transitions were poor, people were not introduced to new people moving into their homes and they did not have a choice about who they lived with. When incidents between people occurred, people were moved out of their homes. A thorough assessment of how people would get along together did not occur which meant transitions were poor.

Staff did not fully understand people's needs or associated risks. Care plans missed important information and provided contradictory and inaccurate information about people’s person-centred needs. The registered manager told us people were involved in their care, made choices about their support and were involved in any reviews of their care but there was no evidence of this. The registered manager told us a person had been receiving care for a month, but a full care plan had not been implemented. Some of the information the registered manager shared with us stated the person had significant health risks such as a history of epilepsy and distressed behaviours such as running in the road. However, there was no robust assessment of risk or specific guidance for staff to follow to support the person. We spoke to a staff member and they had no awareness of the risks associated with this person.

The provider did not ensure there were safe systems, pathways and transitions for people. The registered manager had not identified assessments were not robust or people had no choice or control about who they lived with. People were not fully assessed, and staff did not have the right information to support them. People in supported living were moved if the provider felt they were no longer able to meet their needs. This is not in line with the principles of supported living or the REACH Standards where people should be supported to have full choice and control around the support they receive in their own homes. A staff member said, “No, people who live in their house don’t normally meet new people. If they were here, we might knock and introduce them but generally no.”

While some people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. We were not assured the provider recorded or shared information about all incidents including any safeguarding concerns. There had been an incident where a person had wanted to ‘fight’ another person. The provider failed to take adequate action to support the person or mitigate risks of harm to them. The providers incident report stated further actions needed to be taken and one of the people ‘needed to be warned or sign an undertaking not to go close to the other person.’ There was no information if this had occurred and did not provide any risk mitigation as both people lived in the same house. There was no robust risk assessment placing both people at risk of harm. The provider failed to raise a safeguarding notification in relation to this incident with the local authority safeguarding team and failed to notify the Care Quality Commission of the incident.

The provider and registered manager did not have a good understanding of their responsibilities in supporting people to be safe. The registered manager told us a person had moved into one of the supported living houses a month ago. Despite a pre-admission assessment having been completed important documentation which staff required to support the person was missing. The registered manager told us the care plan was being worked on and did not contain all the information staff required to support the person. The care plan stated the person had medicine to ‘calm them’ but the registered manager told us they did not take any medicine. The care plan said the person was at ‘high risk of ‘flight’ and would run out of the house with disregard for their safety and had run into the road in the past. There was no risk assessment to manage this. The person was at risk of social isolation as they had not left their room for a month. There was no guidance or risk assessment for staff to refer to, to support the person with this. Meeting minutes in June 2024 stated there had been a ‘safeguarding situation mentioning a call from the police and the focus on safety and education’. There was no information about who was involved or what the incident was.

We found that systems to identify and report safeguarding concerns to the local authority safeguarding team, and CQC were ineffective. We asked the provider to share information with us relating to any incidents or safeguarding concerns, but they said they were unable to provide this information immediately. The information they did provide was not complete or reliable. The provider did not identify trends or patterns and lessons were not learned. The provider said incidents were discussed during meetings and action taken. However, meeting minutes gave no specific detail about incidents, or the action taken to support people. This is not a robust way of recording or managing incidents. For example, one person was unable to be woken by staff, and the emergency services had to be called. The incident report stated that the person's blood sugar levels were taken, (low) and queried if the person was 'drowsy' due to their new medication. The provider failed to document any 'outcomes' or 'subsequent actions.' It was not clear if any actions were taken in relation to the person's diabetes, or if their medicine was reviewed. The person's care plan was not updated to reflect this concern. Care plans lacked important information about supporting people, for example, the provider told us a person’s relationship with others could be a ‘challenge’ to manage. There was no risk assessment or guidance for staff to follow in respect of this. Other incidents of concern were not reported to the local authority. For example, one person had set fire to a bin outside their house. There was no risk assessment or information on how the risk was mitigated for other people living with the person.

While some people and relatives we spoke with expressed that they were generally happy with their care, our assessment found care did not meet the expected standards. A relative spoke to us about their relative and said, “She’s lost a lot of weight, but nothing has been said.” Another relative said, “There is a book but there was nothing in it but now they have started writing in it.” People were not supported to take positive risks and restrictions were imposed on certain parts of their life. For example, some people's cigarettes were removed from them so they would not smoke too much. There was no evidence people had been consulted or engaged with about this, their consent sought or capacity to make decisions assessed.

Staff did not have a good knowledge around managing risks to people. A staff member told us there was no system in place to monitor a person who was at risk of constipation and staff would ‘just know’ if there was an issue. We asked another staff member if a person had any associated risks and they said, “not really”. However, the person’s care plan stated they could display certain behaviours which could put themself and others as risk of harm as well as having poor food and fluid intake which put them at risk of becoming unwell.

There was not an effective system to identify and mitigate risks to people. Guidance to support people with complex health needs including catheter care, diabetes management, and constipation were not always in place or sufficiently detailed to inform staff how to support people safely. One person was at risk of constipation, and prescribed medicine to reduce the risk of them becoming unwell. However, there was an incident where the person became so unwell they were hospitalised due to constipation. The incident report stated the person had not opened their bowels for the last couple of weeks. The person had no risk assessment in place for constipation. Staff were not monitoring the person's bowels. The incident report did not state any further actions, for example, to put a risk assessment in place. Five days prior to this, an ambulance had been called for the person, who was suffering from abdominal pain, however the person continued to become unwell. There were no lessons learnt and the provider failed to put any mitigation in place. Other people were at risk of falling but there was no guidance or risk assessments in place to inform staff how to support people safely. Staff told us a person fell and their daily notes confirmed this. However, the provider did not log these as incidents and said the person would ‘roll’ off their bed. There was no robust management of people who were at risk of pressure sores, dehydration or weight loss.

People did not share concerns with us about the environment. However, we found the provider had not considered how people needed support in their environments to remain safe. For example, one person's care records stated, ‘(Person) needs assistance when walking around in case they lose balance. They need a lot of support moving around and transitioning from walking frame to a wheelchair, getting in and out of vehicles, standing up out of bed and in out of the shower/bath.’ The provider had not implemented any clear guidance or risk assessment which outlined how staff should support the person in a consistent or safe way.

Staff told us, “(Person) is at risk of falling. Staff go in the morning and find them on the floor all the time. We keep on finding them on the floor and we keep telling the social worker, the home environment doesn't seem to be suitable for their needs. The provider had not implemented an environmental risk assessment for staff to follow to help reduce the risks to the person. Staff records stated they would help the person back to bed but there was no information how this was completed safely.

Environments were restrictive and not dignified for people. The provider had installed CCTV in all of the supported living houses. There was no evidence people's consent had been obtained or their capacity assessed in relation to this restriction. There was no robust assessment or explanation as to why CCTV was required. In one of the supported living houses, a monitor showing images from the CCTV was in the lounge area that anyone could view, this was not dignified or in line with the associated guidance about CCTV in people’s homes. The provider had installed visitor's books in people’s home, there were separate visitors/staff toilet facilities, an office and signage on walls. This demonstrated a complete lack of understanding of the expectations of supported living or an understanding of the appropriate guidance which providers should follow when people have their own homes and own tenancy agreements.

People's relatives told us calls were not at the right times or cut short which had a negative impact on people. Comments included, “After I fed mum one of them turned up, I said I had fed her, and they gave her medication and went within 5 minutes. I rang the manager, and he said he would deal with it. They say they get stuck in traffic, there's always an excuse.”, “They come at 8am and they are gone in no time.”, “If they have to send new carers I am not warned. If they are running late they let me know most of the time but I do change a wet pad on my own because I cant have him sitting in it for longer than he is supposed to. Medication is important to have at certain times, should be given at 8. They have wanted to turn up at 730. There is a lack of communication between the rota person and the manager.” and “They come at 5 instead of 8. She has taken tablets at 3, she cant take them at 5. I have to go round there at 8 after work to give her the tablets. I have asked them many times to sort the schedule, but they tell me they can't mess up the route. I spoke to (staff) and told them this (staff) lives too far and she tries to do 5 minutes shower and walks out. (Staff member) said I should ring (registered manager). Registered manager said many times they will look into it and they still send the same person because they only have two people on the route.”

Staff did not receive all of the training they needed to support people safely. The training they did complete did not adequately prepare them for their roles. Staff fed back in meetings that training was difficult to absorb due to the volume and time to complete it. Managers told staff to complete it 'even if they did not absorb its content'. There were no assurances the staff completing spot checks on other staff had the qualifications or skills to do so. Spot checks focused a lot on how staff were dressed and if they were wearing their name badge. There was little evidence to demonstrate the competency of staff supporting people with their complex health needs was assessed and checked. The documentation relating to medicine administration and moving and handling competency checks was a question and answer sheet staff had completed. There was no evidence of any practical observations or specific competency checks to ensure staff could support people with their individual needs. This provided no assurance staff delivered care safely. Staff told us they did not always get the support, time off or leave when they needed it and there was not always enough staff. A staff member told us, “We have to tell the management when (person) wants to go out and they put extra staff on Tuesday. (Person) should be able to go out whenever they want.”

We could not be assured people received calls as scheduled. Call logs demonstrated calls were late, there was no travel time in some cases and some calls were short. Staff rosters confirmed calls were booked with no travel time in between and overlapped which meant calls would start early or late and were not always for the full duration. Call logs showed staff logged out of calls from a distance far away from the person’s home where care had been provided, which meant the amount of time they recorded supporting people was not accurate. A relative told us their loved one was not able to go out when they wished because enough staff were not available. We found this was the case for other people. We were not assured the providers ongoing management and recruitment of staff was robust or in line with expected guidance. All staff files we reviewed did not have full employment histories documented with explanations of any gaps, not all work histories detailed why staff left their roles. Checks to ensure staff were of good character to support people were not robust. Efforts were not made to ensure references were secured from previous employers. References did not align with staff members work history. When the provider employed foreign nationals, checks were not made to ensure staff had appropriate right to work in the UK. No overseas police checks had been completed on foreign nationals coming to the UK to work. We made referrals to other agencies regarding the way the provider recruited and managed its staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People had not been involved in making decisions about their medicines. There were no capacity assessments completed, or consent sought from people to agree how they preferred to take their medicines. There was no evidence people were supported to become more independent with their medicines. One person missed their medicines if they went out because there was no system or risk assessment in place to support this. A relative told us call times could impact on their loved one's medicine administration and they would have to support their loved one with medicines to ensure they took it safely at the correct time.

Staff did not have a good understanding around empowering people to take their medicines safely as well as maintaining choice and control in their lives. When we asked staff members why a person had missed their medicine, they told us this is because they had gone out. They had a complete lack of understanding around helping the person implement a system to support them to take their medicines as well as allowing them to live their lives in the manner they chose. Staff did not have a good understanding of what medicine people were prescribed or what had been discontinued.

Medicines were not managed safely. Medicated creams and ointments had not been dated when opened. We asked a staff member if it was normal practice to date these and they said no. Staff were not always documenting when they were supporting people with creams and ointments. For example, one person used a medicated ointment for pain every day, up to 3 times a day. This was not listed on the person's medicine administration record (MAR). Some people had 'as and when' medicines (PRN). There was no guidance in place to inform staff what the medicine was, maximum dosages, when they should have them or why and other medicines which could affect the person. One person was prescribed PRN pain killer which stated it could not be taken with paracetamol, however a staff member told us the person was prescribed paracetamol. When the medicine had been given, there was no information why it had been given, or if it was effective. The provider conducted no medicine audits or monitoring to ensure medicines were correct. There was no system in place to ensure surplus medicine did not build up. One person had 378 paracetamol tablets. However, this medicine was not listed on the person's MAR, and it was not clear when the person had last been administered a paracetamol. Because there were no checks or audits the provider could not be sure all medicine was accounted for. There was no system in place for time sensitive medicine. For example, one person had no risk assessment around an anticoagulant medicine prescribed which must be given within a specific time frame.