Bellamy House (Empowering U Care)

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider maintained clear oversight of incidents and used monthly analysis to identify themes such as triggers, times of day and emerging behaviours. One staff member described the reporting system as straightforward and said, “All the forms are on the app. When we submit the forms, they get sent off, and then we have a debrief afterwards so we can learn from the incident.”

Records showed that incidents were logged and reviewed, with discussions held to identify risks and learning. This learning was shared with staff and used to update care plans and behaviour support strategies to improve future practice.

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.

The provider had effective systems in place to ensure people’s needs were assessed safely and consistently before support was offered. The registered manager explained when referrals were received, they worked with the Integrated Care Board (ICB) to complete a full assessment of whether they could meet the person’s needs safely. This included reviewing the person’s care requirements, assessing whether suitably trained staff were available, and liaising with families and next of kin to gain a full understanding of the person’s circumstances. Where referrals involved manual handling, a specialist assessor was deployed to ensure the service could support the person safely before accepting the package of care. The registered manager also told us they sometimes declined referrals when they could not safely meet a person’s needs. A relative told us, “We moved him from a house to a bungalow in December 2024…. because of his epilepsy. It was seamless.”

The provider worked collaboratively with external professionals during the assessment and transition process to ensure staff had the necessary information to provide safe and appropriate care.

Transitions between services were managed safely. When people required hospital care or admission to another healthcare setting, they used hospital passports to provide professionals with clear information about the person’s communication needs, health conditions, risks and preferences.

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.

Relatives told us they felt their loved ones were safe. One relatives said, “He is safe with 24 hour care. His carers understand him and his needs.”

Staff understood how to recognise and report concerns and were confident in the procedures to follow. One member of staff told us, “If something like that happened, we would go to our manager and ask for advice about what to do next, including whether it needs to be emailed so an investigation can be started. If it needs reporting externally, we can report it to CQC.” Staff had completed relevant safeguarding training and described feeling well supported in their roles.

Safeguarding concerns were documented clearly and reviewed as part of the provider’s oversight arrangements. A safeguarding matrix was in place, and referrals were made to the local authority when required. Records showed incidents, including those involving physical intervention, were logged accurately and incorporated into monthly analysis to support learning. For example, we saw incident reviews which considered factors such as triggers, time of day, staff present, and patterns over time. This included identifying new behaviours noted in December 2025 and recognising a seasonal increase in incidents during November linked to Seasonal Affective Disorder (SAD).

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives felt they were supported to be involved in managing risks. Relatives, told us staff managed risks appropriately, monitored changes and ensured people’s safety inside and outside the home. Risk assessments were person‑centred and took account of people’s communication needs, preferences and known triggers. For people who were non‑verbal, staff understood how people expressed distress and monitored early signs such as pacing, object‑mouthing or changes in mood. This helped staff identify early signs of dysregulation and respond, using de‑escalation approaches tailored to each person.

Behaviour support plans guided staff on the least‑restrictive ways to support people when they became anxious or distressed. Physical interventions were only used when necessary and in line with each person’s plan.

Risk assessments were reviewed regularly to ensure any potential risks were well managed to reduce the risk of harm. Records showed external professionals and families were involved when people’s needs changed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and relatives had no concerns with how they were supported to maintain a safe environment. As people were supported in their own homes, the provider was not responsible for maintaining the premises; however, systems were in place to identify and report any environmental concerns to the relevant teams so issues could be addressed promptly.

Staff understood the environmental risks people could encounter both at home and in the community. Following incidents in public spaces, records showed staff reviewed potential environmental triggers and used this learning to adjust support plans and risk management.

Care plans contained Personal Emergency Evacuation Plans (PEEPS) detailing peoples' individual support needs in the event of an emergency. For example, in relation to mobility or communication difficulties.

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.

Staffing levels were safe and appropriate to meet people’s needs. Rotas demonstrated full shift coverage, and staff were deployed in line with people’s support requirements. Recruitment files showed safe recruitment practices, and staff received a structured induction with opportunities to provide feedback to improve future training. Staff retention was stable at 83%, and most leavers left for career progression.

People were supported by staff who had the skills and training needed to deliver safe care. The registered manager told us, “We have a really well‑trained team here. Staff are highly skilled, and most hold NVQ Levels 2, 3, or even Level 5. There’s a lot of ongoing training too, including resilience training and all mandatory courses, so everyone stays up to date and confident in their practice.”

Training records confirmed staff had completed mandatory training, and specialist training was provided where required. Training also met the standards of the Oliver McGowan Code of Practice, ensuring staff had the knowledge needed to support people with learning disabilities and autistic people.

Staffing levels were planned in advance and had contingency arrangements, such as adverse weather planning which helped ensure support continued during unexpected events.

The provider had effective systems to support and monitor staff performance. Staff received regular supervision and annual appraisals, with the most recent taking place in December 2025.

Care was delivered in a consistent way across the staff team. New staff completed a period of shadowing more experienced colleagues, which helped ensure a smooth and safe transition for both the person and the staff member.

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.

The provider had effective systems in place to prevent and control infection. Staff followed current infection prevention guidance and used personal protective equipment (PPE) to reduce the risk of cross‑infection. One member of staff told us, “We have access to first aid supplies and any PPE we need. We just inform them of what we require, and they place the order. We then either collect it from the main office, or it gets dropped off at the main office near where we are.” Training records we reviewed showed staff had undertaken training in infection control as part of their induction and mandatory training.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely and effectively. Staff followed clear procedures for giving and recording medication, using MAR (medication administration record) charts and PRN (when required) records to document any as‑required medicines. A relative told us, “Meds are all packed up in blister packs, signed for, they [staff] administer meds”. As‑required medicines were monitored through the on‑call PRN monitoring system, with clear records showing when medication was used and why.

One member of staff told us, “Yes, we have MAR charts. For PRN medication, we also have a PRN sheet. PRN is only used as a last resort, once all the person’s usual de‑escalation strategies or support mechanisms have been tried and haven’t worked. If we need to administer PRN, it must be authorised either by the office or by the on‑call manager before we give it.” This reflected PRN medication was only used when needed and in line with each person’s care plan.

Staff received appropriate medicines training and were assessed as competent before administering medication.

Staff reviewed incidents and behaviour patterns to understand whether medication use was linked to any triggers or changes in how people presented. They worked with healthcare professionals when people’s needs changed. For example, after a consultant review, staff saw the person had reduced anxiety and this was reflected in the person’s care plan.