Hampshire Head Office Brockhurst Rd

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 newly registered service. This key question has been rated Requires improvement. This meant people were not always safe and protected from avoidable harm. The provider was in breach of the legal regulation relating to safe care and treatment.

This service scored 59 (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 have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

For example, following an incident where an unauthorised individual entered the property and was verbally abusive towards staff and people using the service, the provider had not reviewed the security of the premises. When we visited, the main door and side gate to the property were open. This demonstrated a failure to review and consult on risk.

Staff did not routinely discuss incidents and safeguarding concerns during team meetings or other structured forums. In addition, managers did not consistently share information related to these issues in a way that supported team learning or encouraged reflective practice. As a result, there was limited opportunity for staff to understand the context of incidents, explore contributing factors, or identify lessons that could inform future care delivery.

This lack of open discussion and shared learning meant the service missed crucial opportunities to reflect on events, reduce potential risks, and implement preventative measures to avoid recurrence.

However, the provider had established a generally open and positive culture. Staff told us they felt confident to report incidents and mistakes and described managers as supportive and constructive in their responses.

The registered manager had begun to review how learning could be better captured, shared, and embedded across the service. Further action is required to ensure governance and learning systems are effective, consistently applied, and lead to sustained improvements in safety and quality of care.

The provider worked closely with people and external healthcare professionals to maintain safe, well-organised systems of care. Staff actively monitored safety and followed clear processes to ensure continuity, particularly during transitions into or out of the service.

Staff used structured referral and assessment procedures to confirm they could meet people’s needs safely and effectively. They received detailed handovers, which allowed them to plan personalised support from the outset. Leaders assessed each referral thoroughly, taking into account individual needs and compatibility with others already living at the service.

Staff supported people with sensitivity during both admissions and discharges, helping to reduce anxiety and promote stability. For example, one person visited the service several times before moving in, gradually increasing the length of their stays to help them feel comfortable and familiar with their new environment.

The registered manager told us that for some people, this had been their longest and most settled placement to date. People and their relatives gave consistently positive feedback, reflecting the provider’s strong person-centred approach and well-managed transition processes. These helped people settle in with confidence and supported a positive, well-coordinated care experience.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always follow legal requirements when using surveillance. CCTV had been installed throughout both indoor and outdoor areas of the service without a documented risk assessment to justify its use. Although people had signed consent forms, these did not clearly explain the risks, benefits, or implications of surveillance.

Although people we spoke with did not express concerns about the CCTV, and the impact on their wellbeing appeared to be low, the provider was not fully upholding people’s rights under the Mental Capacity Act 2005 (MCA).

These shortfalls did not pose significant harm to people and the provider responded quickly and effectively once the issues were identified. They removed CCTV from communal areas during the inspection and committed to reviewing their surveillance policy. They also confirmed plans to carry out appropriate risk assessments and ensure consent processes, including mental capacity assessments, are fully aligned with legal and regulatory requirements.

However, the provider maintained appropriate safeguarding policies and procedures, and ensured staff received training to recognise and respond to signs of abuse or neglect. These actions contributed to a wider culture of safety and protection within the service.

The provider did not always work well with people to understand and manage risks.

People had not always been sufficiently involved in identifying and managing risks related to their care, treatment and home environment. For example, staff monitored 1 person’s food and fluid intake and carried out regular night checks for 2 people. However, there were no risk assessments explaining what the specific risks were or why this monitoring was necessary. One of the 2 people being monitored at night was unable to explain the purpose of these checks but told us they did not mind staff checking on them. This meant that, while the person was not distressed by the checks, they had not been fully informed or meaningfully involved in decisions about their care.

Additionally, the provider had not completed risk assessments for the care provider’s head office, which was located in the back garden of one of the people’s shared homes. Although staff were present on-site continuously, the provider had not involved people in decisions about access restrictions or the use of locked areas within the home. These arrangements were implemented without individualised risk assessments to justify their use or to demonstrate they were the least restrictive option. This limited people’s involvement in decisions that affected their home environment and autonomy.

Care plans for physical health needs were inadequate. Seizure management plans lacked critical information on night-time seizures, Sudden Unexpected Death in Epilepsy (SUDEP) risk, environmental safety, dignity in public, or post-seizure monitoring. Diabetes care was also unsafe. One care plan advised staff to check glucose levels ‘when they feel required’, without any instruction on when this should happen or what actions to take. This guidance failed to support safe, consistent care.

The lack of documented reasoning did not demonstrate the provider had appropriately assessed whether monitoring was proportionate, person-centred, and based on individual risk.

The provider responded promptly to our concerns by completing both general and individual risk assessments, including those relating to property access and care interventions. While further improvements are needed, these actions demonstrate a clear commitment to enhancing safety while promoting people’s independence.

We do not assess the physical environment of supported living settings in the same way as we do in registered care homes, as people live in their own homes. The upkeep and maintenance of these environments is the responsibility of the landlord or housing provider.

The care provider carried out regular health and safety audits to identify environmental risks and maintained oversight of the premises. Staff understood their role in escalating concerns, and the service maintained good communication with the landlord. These systems supported a safe, well maintained and comfortable living environment for people.

The provider ensured there were enough qualified, skilled, and experienced staff to support people safely. They provided staff with training and development opportunities to help deliver effective, personalised care.

People told us that the service benefited from a stable, experienced staff team who worked well together to meet people’s needs. One relative told us, “(Name) believes in Father Christmas and staff help him with elf on the shelf”, “(Name) loves his phone and staff support him with technology if needed”.

The provider implemented safe recruitment processes and completed all required pre-employment checks. Staff kept their mandatory training up to date, and the registered manager actively promoted professional development. The manager encouraged staff to complete vocational qualifications and supported them through regular supervision and team meetings.

The provider assessed and managed infection risks effectively. Staff identified and controlled potential risks of infection spreading, and they shared concerns promptly with the appropriate agencies when necessary. Infection control checks formed part of regular health and safety audits conducted at each supported living house.

An infection control policy, procedure, and cleaning schedules were developed with people to ensure communal areas remained clean. During the assessment, we observed staff supporting people to carry out cleaning tasks in line with the schedules and supporting them to do their laundry.

Bedrooms and communal areas in the supported living houses appeared clean and well maintained. Staff had completed infection control training, and this was documented on the training matrix.

The service did not provide safe or effective medicines management. People were placed at avoidable risk of harm due to unsafe care and treatment. Systems to support safe administration, record keeping, and oversight of medicines were disjointed, inconsistent, or missing entirely.

Staff operated without clear guidance due to conflicting policies, particularly in community settings, resulting in unsafe transcription and record entry practices. During social leave, staff used a dual recording system, both electronic and manual, which created discrepancies. This lack of clarity increased the likelihood of medicine errors, with no assurance that people received medicines as prescribed.

There was significant failure in the audit processes. Despite a known overdose between April and June, staff reported no medicines-related incidents during this period, incorrectly recording the event as a “near miss”. This demonstrated a failure to understand the purpose of audits, which prevented learning from serious incidents and allowed unsafe practices to continue unchallenged.

Medication incidents were not a regular item in team meetings, and there was no evidence of shared learning or improvement.

Medicines records were frequently inaccurate and contradictory. One care plan directed a twice-daily dose, yet the eMAR recorded it four times daily. Another care plan listed a medicine that was not recorded on the eMAR at all. Inconsistent records across care plans, eMARs and medicines passports meant staff could not be sure what to administer, when, or why.

Other areas of practice further compromised safety. PRN protocols lacked person-centred detail, leaving staff without guidance on safe or appropriate use. Self-administration arrangements were unclear, even for people assessed as high risk. Unlabelled and unprescribed medicines were stored without oversight, including an opioid antidote pen, which had no supporting documentation or governance in place. Guidance for the application of pain relief patches, which contained controlled drugs, was generic and lacked critical detail regarding site rotation and documentation. This was unsafe, as failing to rotate application sites can cause skin irritation, reduce the patch’s effectiveness, or lead to a build-up of the medication in the body. Inadequate recording of patch application also increases the risk of errors, such as missed doses, delayed replacements, or accidental duplication.

The provider acknowledged the scale of these failings, but by the time of inspection, people had already been exposed to unsafe care and treatment, with immediate action required to prevent further harm.