Foundation House

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.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation in relation to safe care and treatment, and good governance.

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

The foundations of a learning culture were present, with appropriate systems and processes established to capture feedback, review incidents, and identify and share learning. However, recurring issues indicated lessons learned were not always effectively translated into practice, resulting in some missed opportunities for improvement and reducing the organisation's ability to demonstrate continuous improvement.

This was identified in areas of fire safety and people's prescribed food and fluid textures where effective change had failed to be implemented, embedded or sustained. We found one person continued to be put at risk from a repeated error which did not demonstrate effective actions were being implemented, monitored or followed up. In addition, there appeared to be a lack of understanding from senior leaders in respect of the ongoing actions required to ensure this person remained safe from a reoccurrence.

Staff we spoke with said they were notified of any changes in people’s care needs following incident investigations to help prevent future occurrences. One staff member said, “They [ provider] have a safeguarding team and they handle that aspect, they do a good job. Staff can follow up and see how things have been investigated, they are accessible.”

A previous incident where learning and revision of practice had taken place was shared by leaders around a service phone being taken off the premises by accident. In response to this a signature document was implemented to ensure staff signed any phones in and out when working on shift to prevent a reoccurrence of this event.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

If people required care and support in another setting information was available to be shared to ensure people’s needs continued to be met.

Care and support were planned and organised carefully with people, together with professionals and communities in ways that ensured continuity. Referral information was recorded in people’s care plans and staff spoke about how transitions should be managed and the importance of maintaining the right package of care around the person. One leader said, “Its personalised, we have a waiting list, and we look at a suitable match for the house. We have an aging population now compared to the rest of organisation so we wouldn’t be able to take a younger adult as they wouldn’t have a peer group. Service users would have a say and meet them. Slow transition of visits and overnight stays.”

People were positive about their transition into the service and the support they had received during this period. One person told us, “I wanted to stay, I liked it here. Staff are good here.”

Leaders told us appropriate staff would go with people to support them and help ease any anxieties of being in a new setting. Staff spoke about supporting one person who had been admitted to hospital for a week, explaining how they had travelled to and from the hospital to stay with the person during this time. One leader told us, “Staff work so well with people they want to support them, and we don’t struggle to support this [transitions] as they want to be there.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Whilst we identified improvements were required in relation to notification of safeguarding events the provider showed a commitment to ensuring they approached safeguarding appropriately, and to work in a transparent way with external partners.

People were supported to understand and have an awareness of what being safe meant to them, and how to raise concerns when they do not feel safe, or they have concerns about the safety of other people. We saw posters on making safeguarding alerts were displayed around the service for people and staff to always have accessible information available if required. Although not everyone living in the service would be able to verbalise concerns, we observed people were comfortable in staff presence and regularly sought out staff and leaders for shared interactions, demonstrating established trust and familiarity. Everyone who was able told us they had no concerns relating to their safety, with comments including, “Safe, yes” and “Very safe, overall, its lovely.”

Leaders and staff were knowledgeable in understanding people with a learning disability and autistic people can be at increased vulnerability to abuse and neglect. Safeguarding was a regular agenda item in team meetings, resident meetings and supervisions to ensure safeguarding awareness was maintained through regular dialogue. One staff said, “They [people] may struggle to communicate or recognise unsafe situations, some may be over trusting and have difficulty understanding social cues, making them more vulnerable to abuse. It’s important to create a safe environment, staff training to make sure they can identify early signs of abuse.”

Staff had received training in safeguarding which was regularly refreshed and were able to demonstrate a good understanding of their role and responsibility in ensuring people were kept safe from potential harm or abuse. Staff spoke about knowing people well and being vigilant to recognise any changes in their presentation or behaviour that may indicate further support was needed. One staff said, “We look for signs such as bruises, scars, scabs, areas unwashed, if they are scared when doors are shut, emotional differences, conversations and watching people’s behaviours around others.”

Staff told us they felt confident to raise potential concerns and these would be taken seriously by the management team and investigated appropriately. One staff said, “If you notice any signs of abuse, changes to physical appearance, bruises, scared, unsafe, talk with the resident and make sure they are safe. Report and record factually and report to safeguarding.” Another staff told us, “Safeguarding involves actions and policies designed to protect the person’s wellbeing, health and their human rights and enabling them to live free from harm, abuse and neglect.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). The service had identified people who lacked capacity to agree to the care and support provided. They had followed the correct procedures to ensure they were supporting people in the least restrictive way.

Information relating to people’s capacity and DoLS applications or approved authorisations were clearly recorded throughout care plans and the impact these might have for people’s care and support. One staff said, “We don’t have many residents with DoLS, we do say stop and think, we don’t make decisions for people, we give choice whenever we can.”

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.

The provider was not always effective in ensuring risks were consistently identified, assessed and managed in a way that kept people safe. We found multiple examples where information relating to allergies, dietary needs and health risks was inconsistent across care plans, hospital passports and staff guidance. This meant staff could not always rely on records to support safe decision-making.

Leaders were unclear on who had a food allergy, and we found conflicting information recorded about people’s allergies. A dietary sheet in the kitchen recorded 2 people had food allergies. However, their hospital passport recorded no known allergies.

Another person had fizzy drinks identified as a potential trigger for epilepsy. Staff advised this was an advisory concern raised by family members rather than a confirmed allergy, however this was being followed and withdrawn without further advice been sought. The care plan did not record this information. The hospital passport recorded an allergy to fizzy drinks. Their health passport stated the person does not tolerate fizzy drinks and that consumption may trigger epileptic seizures.

One person had been assessed by a Speech and Language Therapy Team (SALT) as being at increasing risk of choking when eating and drinking. The person’s SALT care plan did not contain the same information as other care plans for this person. The information in the kitchen also did not contain all the information on the SALT assessment. When we spoke with staff they also gave us conflicting information about the person’s needs around eating and drinking. This person was placed at risk of harm as staff could give them food and drink not in line with their assessed needs, this placed them at risk of choking.

There had been 2 incidents since January 2026, involving this person where they had been given the wrong consistency of diet. Following our assessment, the provider told us a full review of all documentation for all people would be undertaken.

Risk information for some people was not clearly recorded in risk assessments. The provider had recognised this and action was planned to address this.

We saw clear examples of positive risk-taking with people being supported through holidays, community activities and healthcare decisions. One person had recently returned from a holiday abroad supported by 2 members of staff that had been carefully planned to enable this person to achieve their travel wishes whilst maintaining their safety.

The service had systems to respond to individual risks and changing needs through care plans, risk assessments and emergency evacuation plans. Fire evacuation arrangements included person-specific emergency evacuation plans (PEEPs) that could be accessed electronically and shared with emergency services if required. Where required people had positive behaviour plans recording how to support people at times of distress. Staff told us they had received training in supporting people around behaviours of communication, and the provider had an in-house emotional wellbeing service to offer further guidance to staff in supporting people with distressed behaviours.

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

At this assessment we found the provider had failed to embed and maintain safe practices around fire risks placing people at increased risk of harm in the event of a fire. We noted multiple fire doors around the service were propped open with various items including metal wedges, rocks or plant pots. We raised our concerns with leaders, however later that day we saw the fire doors in the lounge had been propped open again, indicating this had become a standard practice within the home.

Gloucestershire Fire and Rescue Service had visited Foundation House on 27 May 2025, to evaluate the fire safety provided. They stated some service users were at risk in the case of a fire. One of the actions they identified was fire doors being kept open which meant they would be unable to close in case of fire to protect the means of escape from the effects of fire or smoke, exposing people to harm. We saw it had been recorded on Foundation House health and safetyaction plan this action was complete, however improvements had not been made.

The provider had not ensured safe precautions were followed in line with Health and Safety Executive requirements around window restrictors in the service. We identified that staff had removed one upstairs and one downstairs window restrictor leaving these windows able to fully open and posing a risk. The provider told us this was due to extreme heat, and the upstairs room was not one used by residents. However, the risk assessment did not reflect this practice and following our inspection visit the provider told us the window restrictors had been fixed and newly replaced.

Safe Control of Substances Hazardous to Health (COSHH) practices were not always followed. The sluice rooms in the service were left unlocked with hazardous chemicals accessible (A sluice room is a secure room in a hospital or care home used to safely empty and clean human waste, wash bedpans, and get rid of dirty medical items). During our assessment the provider took action and secured sluice rooms with keypad entry.

There was a system to ensure environmental, and health and safety checks were completed. This included electrical testing, water safety and lift maintenance records. Equipment required to support people was in place and appropriately serviced where applicable. This included bed rails, hoists, wheelchairs, mattresses and commodes. Maintenance arrangements were in place, with NHS services responsible for privately owned wheelchairs.

Maintenance records and fault reporting systems were reviewed and found to be well maintained. Fire alarms and drills were completed in line with requirements and people using the service were involved in evacuation exercises where appropriate. One person told us, “I have seen staff have training drills with an evacuation chair, but not with myself.” Security arrangements were appropriate, with CCTV limited to external areas. No internal CCTV was in operation.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

During our assessment we observed people’s needs being met by enough staff who were visible and available as and when people needed. People and their relatives did share some concerns around call bell waiting times and impacts of staffing levels on some activity attendance commenting, “Gaps in the shift pattern in the last 2 years mean that trips out have to be curtailed” and “Not enough staff to do driving. In recent months I have to get local taxis.” We reviewed the staffing rota, staffing calculation tool and spoke with staff and were unable to identify any inconsistencies in staffing at this time. One staff member told us, “For our workload and activities anytime we feel we need more hands, staff can help with overtime. We have enough staff.”

Staff were recruited safely to the service. This included requesting and receiving references from previous employers, right-to-work documentation and Disclosure and Barring Service (DBS) checks. DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people at the time.

The service considered people’s needs and preferences when staff were recruited, and what personal and professional qualities staff could bring to their work. Staff received a comprehensive onboarding and induction which gave them the skills and knowledge to deliver support in line with the providers expected standards of care.

Staff spoke positively about the training they had undertaken and felt it equipped them with the necessary competencies to perform their roles effectively. Staff told us, “Training is good, they update us and remind us it’s due. They give me a gap when working so I can do my training. I prefer face to face training” and “E-learning training and face to face, fire drills every 6 weeks, we follow the procedures, we leave to gather at the assembly points, look at what went well what needs improving.”

Staff received regular opportunities to share and gather feedback at team meetings and individual supervision sessions. These included key themes which were covered on a rotational basis to ensure staff remained skilled and up to date with internal policies and best practice guidance. Action to support practice where needed was taken in a timely way. For example, a further review would be planned with that staff member within 2 weeks, which included observations of communication, approach, moving and handling, infection control, mealtimes and person centred care.

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.

The provider's arrangements for infection prevention and control required improvement. Although the service was generally clean and free from unpleasant odours, we identified several environmental and practice issues which increased the risk of infection and cross-contamination.

Laundered bedding was left draped over communal grab rails for extended periods. When we queried this with staff, they told us it had been placed there to dry. On 2 occasions we observed staff carrying clinical waste through the service without wearing the appropriate personal protective equipment (PPE). Following this assessment the provider has told us they have taken action to address this with staff.

In communal areas including the lounge, stairwell and bathroom staff were storing their personal belongings and mobility equipment. Following this assessment the provider has informed us more suitable storage areas are being identified.

At the time of this assessment staff were not undertaking deep cleans of people’s bedrooms and told us this had not taken place for some time due to previous reduced staffing numbers. The provider told us they were unaware this had not been happening and was organising for external contractors to complete this.

Staff we spoke with were aware of the procedures to follow in the event of an outbreak, guidance available to them, the appropriate cleaning products to use and how to work to minimise the spread of infection. Staff supported people able to undertake some domestic tasks. One person told us, “Cleaners do it all, but I do my own washing, there is a new tumbler dryer.”

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

Record keeping of medicines requiring additional controls and monitoring was not being completed in a clear and accurate way.

Oxygen was not always stored safely. The appropriate warning level was not in place, and oxygen cylinders had not always been secured. We raised this with leaders who took remedial action to address our concerns.

Some people were prescribed medicines to be administered on a when-required basis for health conditions such as constipation, pain and anxiety. However, guidance in care plans and protocols was not always in place for these medicines to be administered consistently. We further identified care plans were not always in place for people who were at risk of having seizures. Following our assessment action was taken to contact external medical professionals and put these plans in place.

We reviewed records for people who self-administered their own medicines. We found that appropriate and up to date risk assessments were not in place to provide assurance that this was being done safely.

Medicines were administered as prescribed. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both).The records we reviewed provided assurance that medicines were not being used to control people’s behaviour. The staff worked closely with local health agencies and the GP practice to support people with their medicines and health needs.

The staff received training and were competency assessed to handle medicine safely.

Medicines were stored at appropriate temperatures. There was an adequate stock of prescribed medicines.