Vogue Future Living Limited

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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

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 people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, safeguarding people from harm or abuse, safe staffing, consent and governance of the service.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We found during our assessment, that there was a reliance on external organisations to investigate and direct the provider on what actions to take, following an incident or event of concern. There were no internal investigations for recent incidents that had taken place, which would enable the provider to learn from the events, and take action to prevent recurrence.

There were no service improvement plans, or lessons learnt logs for us to view, or anything of a similar nature in lieu of these. The provider, and the managers did not complete audits, and there was no system or process in place to review daily records or incident records that staff complete to identify themes and trends.

Some staff told us that they had raised concerns in the past, and that managers lost sight of the concerns they had and were more focused on reprimanding them for speaking up.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

During our assessment, we found that one person had a hospital passport in place. This is a tool used to document key and vital information about people, to share with health professionals in an emergency situation, such as paramedics, or for hospital staff should they be admitted to hospital. This hospital passport had not been updated since the person moved in, in 2018. It contained out of date information including medications they were no longer taking. No one else had a hospital passport and there were no emergency grab sheets or anything of a similar nature in place to aid a smoother transition in an emergency.

Where people had specific health needs, that required input from an external professional, referrals had not been completed. For example, one person had difficulty swallowing, but there was no input from, or referral to Speech and Language Therapy, to provide guidance and advice to staff and the provider, on how to support them with this need. There was also a significant lack of information available to staff on how to mitigate any risk associated with this need, which left them at increased risk of choking.

Some people attended a day centre service. There was no system in place for handing over vital information to and from the day centre service when they left or returned to their home. For example, we found some people required their fluid intake to be monitored due to certain health needs. There was no system in place to share their current levels of intake, or what they had consumed whilst away from their home, which left them at risk of dehydration.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Providers registered with the CQC are required to submit statutory notifications, for example, where there has been an incident or event of possible harm or abuse. We found that we had not received any notifications from the provider, in almost a year. During our assessment, we observed incident records that would have required a statutory notification be submitted to the CQC to enable us to continually monitor the service. When this was raised with managers, they were not aware of their duty to submit notifications, therefore guidance had to be provided by inspectors

We found that people were subject to continuous care and supervision and were not free to leave their homes, without the appropriate community Deprivation of Liberty Safeguards (DoLS) in place. Although this requires input from the Local Authority, there is a duty on providers to request these, and ensure this is in place before depriving people of their liberty. There was a lack of understanding from the provider and managers on what constituted a community DoLS, and therefore people were unlawfully restricted within their own homes.

We were concerned that people were at risk of organisational financial abuse. This was in relation to how mileage was being charged, when people used the company cars provided. Although at the time of the assessment, this had not impacted anyone receiving personal care, someone with higher mobility needs may be disproportionately charged based on the banding scheme the provider had implemented. At some of the services, people were being charged £2 to use the washing machine and tumble drier by the landlord, despite already being charged a service fee. This concern had been identified by relatives and shared with managers. However, this concern was not raised as a concern by the provider to the landlord, despite being agreed as an action with relatives. These concerns were shared with the Local Authority during our assessment.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments and care plans did not detail what the provider was doing to mitigate risks to people or provide information and guidance to staff on how to manage risks. People had a generic risk assessment in place, that contained the same list of potential risks, even where they were not present. For example, everyone had smoking and vaping listed as a risk, and a corresponding care plan, even where they did not smoke or vape. There was not always risks specific to individual people identified, and therefore there was no information for staff on how to support the person to mitigate and manage the risks. For example, we found two people were at increased risk of falls, due to their reduced mobility, but this had not been identified by the provider, and therefore information and guidance was not provided to staff on how to support them with this need.

Where risks had been identified and applied to everyone, there was not enough detail within care plan and risk assessment documentation for staff to effectively mitigate and manage risks. For example, one person experienced weakness on one side of their body, due to one of their conditions. In their documentation around meal preparation, the same generic risks associated with this task, and generic actions for staff to take had been listed, without consideration for the additional risk they faced when completing meal preparation. For example, the use of sharp kitchen utensils. This meant staff may not have been aware of the risk, nor had the information available on how to support the person with this, and the person was left at increased risk of harm when completing general day to day activities.

We found inadequate evidence that people were involved in risk management, or that positive risk taking was promoted by the provider.

The provider did not detect and control potential risks in the care environment. They did not make sure that facilities supported the delivery of safe care.

The provider did not have sufficient health and safety audits in place which meant they didn’t have enough oversight of potential risks in the environment. There were no systems in place for staff to complete regular health and safety checks, such as checking the temperatures of hot water taps.

We found that one person was not able to leave their flat safely. This person required mobility aids due to their reduced mobility and therefore required a ramp to exit their flat to the emergency assembly point. The person told us they had requested this ramp when they moved into the service in April 2025, but at the time of our assessment, nothing had been put in place by the provider to ensure safe passage out of their flat to the assembly point.

Personal Emergency Evacuation Plans (PEEPs) were vague and lacked detail on how to effectively support someone in an emergency. We found at one service, the PEEPs stated the emergency assembly point was in the car park, however, the emergency lighting and signs indicated that the emergency assembly point was in the garden. Staff also confirmed the assembly point was in the garden.

The provider did complete regular alarm system checks at the services and these were documented.

Relatives told us that they were happy with the support the provider gave them, when escalating environmental concerns to the landlord.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider did not recruit people safely, and there was not a robust system in place to aid this process.

We found that there were no records of the questions people were asked in interview, and the answers they gave, so we were not assured that people were asked questions relevant to the role they were being interviewed for, or that their answers demonstrated their suitability for the role.

Staff did not always have suitable references as we found some only had one, when two is required, and some references were from an unsuitable source. We found that the source of some employment references, had not been confirmed by the provider.

The provider had provisions in place to ensure access to training pertinent to the support worker role. For example, some staff and managers had undertaken “train the trainer training” enabling them to train and assess the competency level of staff in certain tasks, such as first aid, medication administration and moving and handling. The provider acquired online training as their main source of development for staff. However, the provider and managers did not utilise these tools to ensure staff were trained, suitably skilled or knowledgeable in aspects of the role, prior to supporting people. Staff were not assigned, or required to complete, any mandatory training, in the first 12 weeks of their employment, by which point they were already working and caring for people using the service.

When training was completed, competency assessments were not of a good standard and did not truly evidence that the assessor had observed the staff member demonstrating relevant skills and knowledge to complete the care task without supervision.

Staff did not receive all the training relevant to their role, such as catheter care, Acquired Brain Injury (ABI), moving and handling and General Data Protection Regulations (GDPR). We found that staff were supporting people with delegated health care tasks without the proper training or assessment of competency from an appropriate health care professional. This included inserting and removing a catheter tube into someone’s catheter site, in their abdomen, on a daily basis.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found that people were supported to keep their homes clean and tidy. There was adequate provision of Personal Protective Equipment (PPE), and the provider told us they had managed to contain a potential outbreak of an infectious disease earlier in the year. The provider told us they had implemented additional provision of PPE and cleaning products, and kept staff allocated to certain services to reduce the chance of them spreading infection in services not already affected.

There was no infection prevention control audit completed by the provider or the managers, and the provider had not adhered to their own policy, which stated there was a Designated Infection Prevention and Control Lead. There was no lead in place, and the managers had told us they were not aware they needed one.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

During our assessment, we found that medication was not managed safely. There was not adequate oversight within the service in relation to medicines.

We found that senior staff members completed a weekly stock count of medications. The provider referred to this as an audit, however it only consisted of staff members counting the amount of stock left. It was not a thorough audit and there was a lack of prompts to ensure the audit was effective, such as, checking expiry dates, or Medication Administration Record entries. We found out of date topical medication during our assessment, which was also not stored safely. Topical medications were not always included in the weekly stock count so there was not sufficient oversight of these.

There was no system in place to ensure the safe storage of medication, such as thermometers, to check the environment the medication was stored in, was not exceeding the recommended temperature and spoiling medication. When we asked a member of staff how they were sure the medication had not been spoiled in the recent heatwaves, they told us, this person’s “cabinet is kept down low so it should have been fine.”

We found that most medication stock counts, were correct when compared to the weekly stock counts.

There were no pro re nata (PRN) protocols in place, or anything of similar nature. These are used to provide clear guidance and instructions for staff administering PRN medicines. PRN medicines are medicines that should be taken “as required” and not routinely. When we asked the managers for some PRN protocols, they showed us the organisations PRN policy, but had not heard of a PRN protocol before. The managers began to implement PRN protocols during our assessment, but these still did not contain the level of detail expected to aid the safe use of PRN medication.

Medication care plans were not always up to date or reflective. For example, one person had previously been prescribed a gel to apply to an area of their leg, however this was no longer required and had not been required for some months. Their care plan still instructed staff to apply the gel daily.

The provider had a system for over the counter (OTC) medications and information for staff was clear that a pharmacist or GP should be consulted first before staff administered OTC medication to people.