Wilberforce Healthcare UK Limited improved from Requires Improvement to Good across all five key questions, having remediated a prior breach of Regulation 17 relating to medicines management, risk documentation, and governance. The service demonstrated safe, person-centred care with effective multi-agency working, compassionate staff, and a well-functioning management structure supporting continuous improvement.
Strengths
· Risk assessments improved since previous inspection; covert medicines administration and 'as required' medicines protocols now clearly documented and safely managed.
· Safe recruitment system in place with security checks completed before staff worked with people; low staff turnover maintained visit continuity.
· Staff trained in safeguarding with competent office staff handling and referring incidents to the local authority safeguarding team.
· Person-centred care plans updated since previous inspection with regular reviews and flexible visit scheduling to meet individual needs.
· Strong multi-agency working with healthcare professionals and social services to achieve good outcomes for people.
Quality-Statement breakdown (22)
safe: Assessing risk, safety monitoring and management; Using medicines safelyGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced diet; Supporting people to live healthier livesGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careGood
Wilberforce Healthcare was rated Requires Improvement overall following a comprehensive inspection in May 2017, conducted after an enforced three-month registration suspension due to serious regulatory breaches found in October 2016. Significant improvements had been made across all five key questions, but ratings could not be raised beyond Requires Improvement as consistent and sustained improvement over time had yet to be demonstrated.
Concerns (8)
criticalStaffing levels: “the registered provider could not deploy suitable numbers of staff to meet the needs of the people who used the service, which led to people experiencing missed calls.”
criticalMissed or late visits: “We used to be rushing from one call to the next, leaving early to try and get to the next one on time but all that's has stopped now.”
criticalIncident learning: “the registered provider had failed to notify the Commission of an event that prevented the service provider's ability to continue with a regulated activity safely.”
criticalSafeguarding: “the registered provider had failed to ensure people were not exposed to risk of abuse by way of neglect. People...had their care calls delivered in significantly reduced timescales.”
moderateGovernance: “we could not rate the service higher than requires improvement for 'well-led' because to do so requires consistent and sustained improvement over time.”
moderateCare planning: “people did not receive person centred care and their care plans lacked information to enable staff to deliver care in line with their preferences.”
moderateStaff training: “staff had not completed relevant training and were not supported in their roles.”
moderateComplaints handling: “complaints were not recorded and investigated as required.”
Strengths
· People told us they felt safe and staff had not missed any calls since the suspension was lifted in January 2017.
· Staff completed safeguarding training and were knowledgeable about types of abuse and reporting responsibilities.
· Medicines administration records were completed without omission and medicines competency checks were carried out.
· Staff received community and branch supervisions on a three-monthly basis and felt well supported.
· People were supported by small, consistent teams of staff who knew their preferences, promoting dignity and continuity.
Quality-Statement breakdown (14)
safe: Protection from abuse and avoidable harmGood
safe: Staffing numbers and safe recruitmentGood
safe: Medicines managementGood
effective: Staff training and inductionGood
effective: Supervision and professional developmentGood
effective: Consent and Mental Capacity Act complianceGood
effective: Nutrition and healthcare accessGood
caring: Person-centred care and knowledge of preferencesGood
Wilberforce Healthcare received an overall Inadequate rating following an October 2016 inspection that found multiple regulatory breaches, including chronic staffing failures resulting in over 100 missed care calls, staff routinely leaving visits after less than four minutes, absent care plans and risk assessments, no staff supervision or appraisals, and a near-total absence of governance and quality monitoring systems. The service was placed in Special Measures, with the registered manager acknowledging: 'I knew we had loads of problems, we knew something serious was going to happen to someone.'
Concerns (14)
criticalStaffing levels: “The registered provider could not deliver commissioned care to 17 people totalling 102 care calls between 8 and 9 October 2016.”
criticalMissed or late visits: “Staff arrived up to 179 minutes late and up to 177 minutes early to care calls. 52 calls were completed in less than 10 minutes and 19 were completed in less than five minutes.”
criticalSafeguarding: “People were exposed to the risk of abuse by way of neglect because the registered provider could not deploy sufficient numbers of staff.”
criticalCare planning: “Care plans had not been created for two people who used the service and other people's care plans failed to reflect people's current support needs.”
criticalMedication management: “Staff arrived 101 minutes late to a scheduled call which meant the person did not have their medicines at the required three hourly intervals.”
criticalStaff competency: “Newly recruited staff with previous experience working in the care sector were allowed to support people without having their skills and abilities checked.”
criticalGovernance: “The registered provider's quality monitoring systems were inadequate. There was no evidence to show that auditing of care plans, risk assessments, staff training and supervision... was carried out.”
criticalRecord keeping: “Complete and contemporaneous records were not held regarding each person who used the service. Two people who used the service did not have care plans.”
criticalIncident learning: “The registered provider failed to inform the Commission as required of their inability to provide care and support to people who used the service until 10 October 2016.”
criticalLeadership: “The registered manager told us, 'I knew we had loads of problems, we knew something serious was going to happen to someone.'”
moderateSupervision / appraisal: “None of the seven staff files we looked at contained an annual appraisal, even though staff had worked for the registered provider since 2013.”
moderateStaff training: “One member of staff completed assessments of people's needs before producing care plans and risk assessments... they had not completed training in this area.”
moderateComplaints handling: “Five complaints contained no information except for the complaint, no acknowledgement, no investigation and no response.”
moderatePerson-centred care: “The care plans we saw did not contain personal information about people such as their hobbies and interests, their family lives or the previous occupations.”
Strengths
· People confirmed that consent was obtained before care and support was delivered.
· People who used the service were supported to eat and drink sufficiently.
· Care plans and sensitive information were stored securely in locked cabinets with password-protected electronic access.
· Some people reported individual carers as caring and pleasant, and some had consistent regular carers.
· The service worked alongside a range of professionals such as community nurses and GPs.
Quality-Statement breakdown (18)
safe: Staffing levels sufficient to meet needsInadequate
safe: Care delivered at agreed times and durationInadequate
safe: Risk assessments in placeInadequate
safe: Safe recruitment practicesInadequate
safe: Medicines administered safely and on timeInadequate
safe: Business continuity planningInadequate
effective: Staff skills and competency assuranceInadequate
effective: Supervision and appraisal of staffInadequate
Wilberforce Healthcare UK Limited was rated Requires Improvement overall at this July 2018 inspection, with breaches of Regulation 17 identified relating to missing medication records, absent PRN and covert medication protocols, inadequate risk documentation in care plans, and ineffective governance systems. The service demonstrated strengths in staffing, staff training and supervision, caring practice, and infection control, but failed to maintain contemporaneous records or robust quality assurance processes.
Concerns (9)
criticalMedication management: “One person's medication administration records (MAR's) were missing, therefore there was no evidence to show staff had recorded or administered this person's medicines, as prescribed.”
criticalMedication management: “Staff were not provided with protocols for administering 'as and when needed' (PRN) medication.”
criticalMedication management: “There was no guidance available to staff to administer one person's medication covertly.”
criticalGovernance: “There was no formal system in place for carrying out or recording these checks had been made.”
moderateCare planning: “Risks were not always recorded clearly in people's care plans. This meant staff did not always have access to current information about people's needs and ways to minimise risks.”
moderatePerson-centred care: “Care plans contained minimal person-centred information about their routines, life history, hobbies and interests.”
moderateRecord keeping: “People's care files did not always contain records of reviews held which reflected what had been discussed or agreed at the meeting.”
moderateIncident learning: “The registered manager did not have oversight of accidents and incidents, so patterns and trends could not be identified.”
moderateIncident learning: “From speaking with staff, we identified that there had been some minor incidents which should have been recorded.”
Strengths
· Staff were recruited safely with written references and enhanced DBS checks in place before starting work.
· Sufficient numbers of staff available with people reporting regular carers providing continuity of care.
· Staff received effective supervision, yearly appraisals, induction with shadowing, and a range of training.
· Principles of the Mental Capacity Act 2005 were followed and consent was obtained before providing care.
· Staff were caring, treated people with dignity and respect, and promoted independence.
This focused inspection reviewed Wilberforce Healthcare following an urgent suspension imposed after widespread regulatory breaches found in October 2016, including over 100 missed care calls, severe neglect through curtailed visits, absent care plans, and ineffective governance. The service was inspected but not rated across all five domains as it was not delivering regulated activity at the time; the suspension was lifted after the registered provider demonstrated revised policies and planned systems, though their practical implementation could not be verified.
Concerns (12)
criticalStaffing levels: “inability to deliver care and support to 17 people during the weekend of 8 and 9 October 2016, which equated to over 100 care calls”
criticalSafeguarding: “81 calls were delivered in less than half of the time staff would need to deliver the care the person required. 52 calls were completed in less than 10 minutes”
criticalMissed or late visits: “records also showed staff arrived up to 179 minutes late and up to 177 minutes early to care calls”
criticalCare planning: “care plans did not reflect people's current level of needs and lacked pertinent information they needed to deliver the care people required safely”
criticalPerson-centred care: “One care plan contained no information about the person's needs so staff delivering care would not have known what the person required assistance with”
criticalStaff training: “None of the staff files we looked at contained an annual appraisal, even though staff had worked for the registered provider since 2013”
criticalSupervision / appraisal: “There were no supervision records available in any of the staff files we looked at.”
criticalStaff competency: “one of the DBS checks showed the person had a number of recent convictions. There was no risk assessment or record of any conversation with the staff member”
criticalGovernance: “They did not operate effective governance systems and relied upon ad-hoc checks to monitor the quality of service delivery.”
criticalIncident learning: “The registered provider failed to inform the Commission as required [of their inability to deliver care calls to 17 people on 8 and 9 October 2016].”
moderateComplaints handling: “Internal investigations had not taken place and subsequently the service had failed to learn from any of the concerns raised”
moderateRecord keeping: “due to the poor record keeping and lack of information in the service we could not conclusively determine when or how the complaints were received”
Strengths
· Registered provider acknowledged failings openly and described planned improvements across all areas
· New policies, procedures and supporting documentation developed to underpin improved processes
· IT systems planned to automate alerts for supervision, spot checks, training updates and care reviews
· Call monitoring system introduced to track staff arrival and departure times and flag early departures
· Suspension lifted following satisfactory review of planned remediation actions
Wilberforce Healthcare received a Good rating across all five key questions at its December 2015 inspection, demonstrating safe recruitment, adequate staffing, well-trained and caring staff, and robust governance systems. No regulatory breaches or failure themes were identified.
Strengths
· Staff trained to recognise and report abuse; safeguarding records maintained and analysed for patterns
· Safe recruitment practices including DBS checks and reference verification
· Sufficient staffing levels maintained, including double-up calls where required, with computerised monitoring of visit attendance
· Staff received regular training, supervision, and annual appraisals with competency assessments and spot checks
· Person-centred care plans formulated with involvement of people using the service and their relatives
caring: Dignity, respect and confidentialityGood
responsive: Complaints policy and handlingRequires improvement
responsive: Involvement in care planning and reviewGood
well-led: Quality assurance systems and governanceGood
well-led: CQC notification of notifiable eventsGood
well-led: Feedback processes and continuous improvementGood
effective: Mental Capacity Act compliance and consentGood
effective: Support with nutrition and hydrationRequires improvement
caring: Staff treat people with dignity and respectRequires improvement
caring: Person-centred approach and knowledge of preferencesRequires improvement
responsive: Care plans reflect current needsInadequate
responsive: Reviews conducted when needs changeInadequate
responsive: Complaints handling and learningInadequate
well-led: Quality monitoring and governance systemsInadequate
well-led: CQC notification of notifiable eventsInadequate