Axis Care Group Ltd

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. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to medicines not being managed safely, involving people to manage risks and safe recruitment processes.

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.

There were some instances in which incidents were not recorded meaning lessons were not always learnt to continually identify and embed good practice.

People/relatives told us about incidents which had occurred. These were not always recorded, meaning there was an increased risk of harm and learning not being fully embedded.

The provider did not always complete investigations into incidents in a timely manner. For example, where a person had suffered a fall. This provided limited assurance the provider was reviewing incidents promptly to identify learning and reduce the risk of reoccurrence.

The provider did not have robust systems in place to monitor people whose behaviour communicated a need or distress. The daily notes clearly showed how there were various occasions in which a person was distressed or agitated but there was no analysis of this completed, nor was there evidence of effective recording systems such as antecedent, behavioural and consequences (ABC) charts being used.

However, the provider had policies in place which were readily accessible to staff, and they were aware of how to report safety events.

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.

People had hospital passports in place. Hospital passports are documents which are created so that when a person goes into hospital, the staff have something they can refer to which contains the most important information about them, including what medication they are taking, their main diagnoses and more personal items including their likes, dislikes and their religion.

A person was supported to attend a medical appointment regularly throughout the week. Whilst at the person’s property, we witnessed how care staff prepared the person for the appointment and liaised with the ambulance staff well to ensure the person was transported effectively.

Staff felt people’s transitions into the service had been smooth, and they were able to explain how the people supported, had thorough assessments and how multiple professionals had been involved throughout this stage.

Partners were complimentary of the way the service had safely and effectively transitioned people into the service. A social worker stated, “[The provider] helped ensure a safe transition for [person]…by coordinating with professionals, sharing risk information, and completing pre-transition planning.”

People’s daily notes evidenced how staff contacted professionals when required. This included contact with a GP and the Crisis Mental Health Team (CMHT).

The provider did not always share safeguarding concerns quickly and appropriately.

The provider did not provide evidence they escalated safeguarding concerns appropriately to the local authority. They provided examples of incidents relating to people since they had joined the service, but investigations did not indicate that referrals had been completed, but rather that the social worker for the person had been updated. Furthermore, the provider had sent us data which contained details of incidents, one of which should have been reported to safeguarding but had not. It is important to inform the local authority safeguarding team as it helps to identify patterns of harm, ensures appropriate oversight, supports transparency and accountability and enables early intervention. The update made to the person’s social worker for a safeguarding incident was not timely with this being 7 days following the concern being identified.

A person/relative told us about an incident which had not been investigated which required staff to safeguard the person.

However, people and relatives did not share any concerns in relation to their safety or the quality of the care and support they received. People appeared relaxed in the company of staff. People and relatives told us they or their loved ones were safe.

Staff had received training on safeguarding children and safeguarding adults and had a good understanding of what would constitute a safeguarding concern and how to escalate this, in line with their internal policies and procedures.

The provider had a safeguarding adult’s policy and procedure which was last reviewed in 2026. This contained all the appropriate details within it and had specific contact details for the local authorities.

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.

Staff were using a wooden chair in a shower for someone who required a shower seat. When this was discussed with staff as inappropriate, they explained how the occupational therapist had ordered a chair, but it had not arrived. The provider had not considered a more suitable interim measure and the use of the wooden chair in the shower had not been risk assessed. We have been assured the person now has a shower seat in place.

The provider had missed some important risk assessments for people who required them to be in place. For example, a person who was identified as being at risk of choking, had medical conditions which impacted on their appetite and digestion, required support with eating and drinking and were at risk of dehydration and malnutrition did not have a nutrition or hydration risk assessment in place. Another person, who was at risk of falls and staff confirmed they had fallen whilst being in the service, had a risk assessment in place, but there was no mention of falls within their care plan.

A person’s care plan and risk assessments regarding moving and handling did not contain the appropriate detail to support them. There was no mention of the person’s ability to stand from sitting or to sit from lying and the levels of assistance needed or specific techniques or guidance required.

People’s care plans did not always contain the detail which was contained in the risk assessments. For a person, who had been identified as being at risk of pressure sores, there was no mention of this within their care plan and the need to reposition. Care plans are the operational guide which staff follow day-to-day so should be current.

The provider failed to evidence regular minuted meetings with the person or their representatives regarding their care. Given people had recently moved into their accommodation, we would have expected regular communications and meetings between the provider and the person, representatives or professionals.

The provider ensured people who displayed behaviours that challenged and were often linked to unmet needs, distress, communication difficulties, trauma, mental health or environmental triggers, had a positive behaviour support plan (PBS) in place. PBS plans had not been led or reviewed by a suitably qualified professional, such as a psychologist, behaviour specialist or learning disability nurse. The provider told us this was a temporary measure pending multi – disciplinary input but we did not see evidence this had been arranged.

The provider responded well to feedback regarding care plans and risk assessments, they have started to make improvements, and this is part of a longer term improvement plan.

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

The provider was unable to provide evidence demonstrating how they assured themselves in relation to health and safety checks, including external fire risk assessments being completed for the people’s premises. This meant we could not be assured systems were in place to effectively monitor and mitigate risks to people’s safety.

The provider had completed risk assessments for people’s homes which included the use of electrical equipment, smoke detectors, radiators and COSHH (control of substances hazardous to health). When we visited one of the properties, some of the risks identified were not mitigated as stated in the risk assessment. For example, a cupboard which contained body washes and shampoos was not locked, the radiators were not cool touch, and the furniture was not fire retardant, as stated within the risk assessment.

The provider was recording refrigerator and freezer temperatures. The refrigerator temperature should be between 1 and 4 degrees Fahrenheit but there were occasions when it had exceeded that. Furthermore, there were also occasions when the freezer temperature had exceeded -20 degrees Fahrenheit which had the potential to damage foods.

However, people’s properties were laid out well with ample room to relax in the lounge areas and help prepare foods in the kitchen, were clean and tidy, secure, had furnishings, were painted well and had the appropriate fire signage.

The provider had ensured there were weekly checklists in place for carbon monoxide, the smoke alarm and thermometer probe checks. There was also evidence of monthly safety and governance checks in place.

People had personal emergency evacuation plans (PEEP) in place. PEEPs are used to tell staff how to support someone to evacuate safely in an emergency. The PEEPs were detailed and person centred. The provider also ensured people had detailed fire risk assessments in place which were person centred.

The provider did not always make sure staff completed all mandatory training. They did not ensure all appropriate documents were observed/stored when staff were recruited.

The provider maintained a training matrix which indicated high overall compliance. However, they did not evidence completion of advanced autism and learning disability training, despite supporting people with these needs. Furthermore, most staff did not have in person training for moving and handling. Electronic learning was in place which covered the theory, however, where staff are physically supporting people there should be practical training and competency assessments in place.

Recruitment records were not consistently complete. Some staff files did not contain proof of identification, proof of address or contracts of employment. Interviews were sometimes conducted by a single staff member rather than two, and in some cases by staff who were not in senior positions which is not in line with best practice.

The onsite induction or shadowing checklist reviewed did not include details of shadow shifts completed, evidence that staff had been observed and had practiced key tasks, or confirmation that staff had demonstrated competence in areas such as following care plans, recording and reporting appropriately, and supporting people safely. This meant it was not clear whether staff had been fully assessed as competent before working independently, which may increase the risk of inconsistent or unsafe practice.

The provider sent evidence of staff rotas, but these were unclear. For example, they did not indicate how 2 staff were on shift at once which was an assessed need for a person when they required a shower.

The provider did evidence regular supervisions and appraisals taking place by senior members of the team.

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.

People’s homes were clean, tidy, free from clutter and no malodours were identified.

People’s food goods which had been opened, were stored in clear food bags which were dated when they had been opened to avoid foodborne illnesses.

Staff had been trained in infection prevention and control (IPC).

The provider was completing monthly IPC audits which included reviewing the cleanliness of the environment, high touch points being clean, personal protective stock levels being adequate and waste management.

The provider needed to ensure all hand sanitiser within the people’s homes was in date as we identified some which had expired which reduces its effectiveness.

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.

Medicine administration records (MARs) were being used by the service to confirm the administration of medicines by the care staff. These MARs were being created by the service themselves but the information being recorded was not of a sufficient quality to meet national guidance.

People’s allergies were not being clearly recorded, doses to be administered did not match what had been prescribed by the GP, the details of the person’s GP were missing and special instructions for the administration of some medicines were not evident. The missing information does not ensure medicines would be administered safely.

Additional information about the administration of medicines prescribed on a when required basis were present in the form of ‘when required’ protocols. The information, included in these plans was not sufficient to inform the staff of how and when it was appropriate to administer these medicines.

Assessments about what support from the provider people needed to manage their medicines was in place however the conclusion of these assessments did not accurately reflect what was happening in practice.

Supporting information to assist staff in managing medicines showed who was responsible for the ordering, collecting, and storage medicines.

The medication risk assessments did not always identify the risks associated with the administration of some medicines.

Staff that administered medicines had completed safe management of medicines training and had undergone an assessment to check their competency to administer medicines safely. The specific details of what was assessed was not evident and the provider may find it beneficial to access the Skills for Care guide on Medicines Competency Assessments in Adult Social Care settings.

Audits for the management of medicines were being carried but were not robust enough to identify some of the issues identified during this assessment.