TheSignLife Project

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.

This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. Throughout the assessment process, it was identified that risks associated with service users’ care and support were not consistently identified, assessed, or mitigated. Medication management and documentation were insufficient to reduce the potential risk of harm to people using the service. Recruitment systems were also found to be neither robust nor effective. The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

This service scored 53 (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 demonstrate a proactive and positive culture of safety based on openness and honesty. While some incidents were discussed with inspectors and staff were able to describe actions taken, the written records lacked sufficient detail, outcomes, and evidence of follow-up. There was no safeguarding log in place, and no formal action or improvement plans were available for review, therefore we could not evidence lessons had always been learnt to continually identify and embed good practice.

Some learning was shared during team meetings. Minutes showed staff were encouraged to reflect on situations and identify areas for improvement. For example,1 meeting reviewed how a person receiving support situations had been handled, with discussion on what had improved and what still needed work. It was discussed that staff also had access to tools such as the 999 British Sign Language (BSL) App to support clients in emergencies, which reflects some proactive thinking.

The provider shared examples of adapting their approach based on past experiences. They had trialled supporting people who were hard of hearing, but found communication was challenging. As a result, they chose to focus on supporting people who are profoundly deaf and use BSL, aligning better with staff skillset. This shows some learning and responsiveness to both staff and client needs.

There was no complaints data available, and limited written evidence of learning from incidents. This makes it harder for the service to embed good practice consistently. However, the team appeared committed and shared they regularly had meetings with visual aids to follow up when things need to be actioned.

Both relatives and staff said they knew how to raise concerns. Staff were matched with people who are profoundly deaf, enabling clear communication. One relative said the manager “always listens and takes action.” People with a learning disability were mainly supported by familiar staff, which helped build trust and consistency. One relative shared, “We have regular staff who we know.”

The provider acknowledged the need for clearer systems, such as a safeguarding log, and showed willingness to improve. These steps are encouraging but need to be formalised and embedded to ensure a stronger learning culture. The use of consistent staff, open team discussions, and accessible communication methods helps reduce the risk of a closed culture.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, where safety was actively monitored and managed. There was evidence of continuity of care, including when people moved between services.

Initial assessments were carried out following referrals from the local authority, with an independent interpreter present to support communication. Staff described a clear process involving contact via letter, email, or phone, followed by a home visit to understand the person’s wishes and needs. Care plans were developed based on this information, and staff were matched appropriately to each individual. One relative shared, “The company was recommended to me and I’ve felt supported from the start.” A staff member explained, “When I receive a new person to care for, the team leader leads and I shadow for the first time to make sure we go through all the needs together.”

The service used an electronic system that enabled staff to access care plans, record notes, and view updates from previous visits. This supported continuity and safety, particularly around completing personal care tasks. Staff could clock in and out, which helped evidence increasing support needs when call times ran over. This evidence based information was used to secure appropriate funding from the local authority in order to help meet the needs of individuals.

The provider did not always work effectively with people and healthcare partners to understand what being safe meant to them or how best to achieve it. While staff showed some awareness of safeguarding, systems and oversight were inconsistent, and there were gaps in training, documentation, and risk management.

Training around safeguarding was not always up to date according to the provider’s training matrix. When speaking to staff about safeguarding training, they could recall completing it in the past, but one staff member said, “I’m not sure when I last did it.” There was no safeguarding log in place and no notifications had been made to the Care Quality Commission (CQC) about any safeguarding concerns which had been raised. This lack of formal reporting and tracking limits the provider’s ability to monitor safeguarding concerns and respond appropriately. There were also significant gaps in how financial safeguarding was managed. Staff supported people with purchases using cash or contactless cards, but there were no clear policies or consistent documentation in care plans or risk assessments. The manager stated that receipts submitted by staff would be checked, but no further guidance or oversight was in place. Whilst no processes were documented, staff mentioned that receipts should be photographed and uploaded to an app, but without formal procedures, this presents a risk of financial exploitation or error. However, on assessment we did not find any harm caused to people from this lack of evidencing. Following the inspection, the provider has taken steps to include clear details in people’s care plans about how they should be supported with their finances and how to mitigate risks associated with handling money.

Whilst training records were not always up to date, staff were able to describe what safeguarding was, with one saying, “We need to protect people against abuse.” Another staff member shared an example of raising concerns about a person to their manager. This shows staff were willing to escalate concerns when they felt something was not right. Relatives generally felt confident that concerns would be shared. One said, “The manager will call to let us know if there are any issues. They are always open about anything going on.” They also added, “We haven’t complained, but if we had any concerns, we would report them to the manager.”

The provider did not always work well with people to understand and manage risks. While there were examples of people being supported to make choices, care planning and risk management were inconsistent and did not always ensure safe, person-centred care.

People were supported to make decisions about their daily activities. One relative said, “[The person] is ready and waiting for staff and tells them what they want to do and then staff support them to do those things”. A staff member added, “I always give choices,” and explained they read care plans to understand each person’s background and support needs. Another staff member mentioned “Sometimes they [person] want to do a specific activity and I help them arrange this and the support they will need for that activity. This gives the person freedom and allows them to feel supported and confident in their lives.”

Care reviews were held, and relatives confirmed they were involved. One relative said, “They [the registered manager] come annually with an interpreter and ask if there are any concerns. At the last review, we discussed how they could help with bathing.” Staff confirmed that changes were made and shared through meetings, updated care plans, and notifications to funders.

Staff supporting a person with complex communication needs described challenges in encouraging personal care. One staff member said, “It takes a lot of encouragement but we know [the person] well and how to recognise when they become distressed.” This shows staff familiarity with individuals, but also highlights the need for clearer guidance in care plans.

Risks however were not always clearly identified or managed. Daily logs showed that 1 person declined showers frequently over two months, but their care plan did not address potential risks such as poor hygiene or skin issues. There were also contradictions in documentation, such as differing staff requirements and healthcare visit schedules, which could lead to confusion and unsafe care.

The provider did not always detect and control potential risks in the care environment.

Fire safety procedures were not consistently embedded in practice. Care plans lacked fire risk assessments and evacuation plans, and staff had no written guidance on their responsibilities in the event of a fire. This posed a serious risk that staff may not respond appropriately in an emergency, potentially causing distress to people using the service. While staff were able to describe basic actions they would take, such as evacuating individuals and contacting emergency services using BSL 999, this knowledge was not supported by formal documentation or consistent training. One person who smoked had no risk assessment in place to guide staff on mitigating fire risks, increasing the potential for harm if staff were not vigilant. One staff member recalled receiving fire safety training when they first joined, but this was not consistent across the team. There was also no evidence of regular review or reinforcement of fire safety procedures.

Some staff demonstrated awareness of environmental risks, such as ensuring bathroom floors were cleaned and dried to prevent slips. However, these practices were not systematically documented or monitored. Following the inspection, where these concerns were identified, the provider began updating care plans and risk assessments to include fire evacuation details and staff responsibilities.

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

Training systems were disorganised and inconsistent. Staff recalled completing training during induction but said refresher training was not always consistent. Two separate training spreadsheets were used, both showing gaps and outdated records. Medication, safeguarding, and moving and handling training were not always up to date. The lack of up-to-date records highlights a gap in oversight and increases the risk that staff may not be adequately prepared to meet people’s needs safely.

The service is registered to support individuals with dementia, mental health conditions, and learning disabilities. While no individuals with dementia were being supported at the time of inspection, the service did support people with mental health conditions and learning disabilities. Training records showed that only a small number of staff were in date for learning disability and mental health awareness training, with many either out of date or having no documentation. These inconsistencies make it difficult to confirm staff competence in supporting individuals with varying needs.

Medication training records were also inconsistent. Across both spreadsheets, at least two staff had no record of completing any medication training. Although the manager stated that all staff had completed medication training, no evidence was provided. Staff recalled completing medication training when they first joined but could not remember completing any medication training since.

Recruitment practices were also not always safe. Some staff files had unexplained gaps in employment history, and only one reference was typically sought. One staff member had a DBS check under a previous employer, and no updated check had been obtained. Interview notes were not kept, and while interviews were conducted in British Sign Language (BSL), the lack of documentation compromises transparency and safety. The provider has stated that going forward, a note taker will be present during interviews to record these conversations.

The provider confirmed that spot checks were carried out to monitor staff practice, but these were not documented. Staff and people using the service were aware that observations took place, but there was no clarity on how often they should happen or what they were for. The provider has since introduced a spot check form to record these observations and to support staff more clearly, but a structured process for when these checks occur still needs to be embedded.

Despite these concerns, staff appeared to know the people they supported well. A relative told us, “They are quite friendly and just get on with it. The biggest thing is around communication and they can do BSL which enables staff to best support [individual].” Staff told us they felt supported and had regular contact with their line managers. One staff member said, “I am able to share my ideas and opinions. I don’t feel like they are ignored,” and another confirmed, “Every month we have a supervision or team meetings.” Staff could choose their preferred supervisor and interpreter, which helped make supervisions more accessible.

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.

Staff demonstrated good infection control practices. One staff member told us, “I use gloves to administer medication or help with personal care. I always change my gloves between tasks and ensure everything is clean.” Staff also reported regularly washing their hands during visits and checking food in people’s fridges to ensure it was in date, with all food clearly labelled. A relative told us, “Staff wear gloves and an apron to support with personal care.” Personal protective equipment (PPE) was readily available, with supplies stored at the office and in staff cars, allowing quick access when needed. Office staff also dropped off PPE to people’s homes when required. These practices helped ensure safe and hygienic care was delivered consistently.

The provider did not make sure that medicines and treatments were safe or met people’s needs, capacities, and preferences. People were not consistently involved in planning their medication support.

Care plans lacked essential information about medication side effects, contraindications, and allergies. There was no detail on the level of support required for administering medication or how staff should seek consent. This increases the risk of unsafe administration and undermines people’s rights to informed decision-making.

One person’s care plan mentioned diabetes but gave no guidance on how staff should respond in emergencies, such as a hypo or hyperglycaemic episode. Although this was not documented, staff were able to describe how they recognise when the person’s blood sugars are low and what actions they would take. Another person’s medication was locked away with no guidance on access outside of staff visits, which could lead to unmanaged pain or delayed treatment. Medication administration records (MARs) showed inconsistent recording practices. Staff used varying codes such as “absent,” “missed,” and “other,” without clear explanations. The manager stated that “other” referred to As and when needed (PRN) medication not being needed, but this was not documented clearly, increasing the risk of errors and miscommunication.

There was no guidance on what staff should do if a person refused medication, and the manager was unclear whether medical advice should be sought in these cases. This lack of clarity could result in unmet health needs and potential harm. Staff confirmed they received medication training during induction but could not recall any refresher training. No competency checks had been completed to ensure staff were safe and skilled in administering medication. While staff felt confident and described their routines with people, this was not supported by evidence of ongoing training or oversight. Although no harm or medication errors were identified during the inspection, the absence of clear protocols, training, competency checks, and documentation presents a significant risk to safe care. The provider had a thorough medication policy, but it was not being followed in practice.