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.

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 the person 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.

Staff understood how to recognise and report concerns and were confident in the procedures to follow. They explained that visual checks were carried out after personal care, and any marks were recorded and reported promptly.

One staff member told us, “If we notice any new marks or bruising, we document it straight away and report it to the office so it can be followed up properly.”

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.

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.

Risk assessments were person‑centred and reflected the individual’s communication needs, behavioural patterns and known triggers. Staff described how they monitored the person’s presentation throughout the day and used this information to plan activities safely, including whether accessing the community was appropriate.

Behaviour support plans guided staff including agreed strategies to manage behaviours that could place the person or others at risk. Staff told us that decisions were made collaboratively and reviewed daily based on the person’s mood, behaviours and any emerging triggers, ensuring the individual remained involved as much as possible in how risks were managed. Risk assessments and behaviour support plans were reviewed regularly to ensure they remained current.

Records demonstrated that person’s safety risks were considered. For example, risks relating to skin integrity, falls and mobility were assessed, and appropriate plans were in place to meet individual needs and minimise these risks.

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

The environment was adapted to meet the person’s individual needs and promoted their safety and wellbeing.

Staff demonstrated an understanding of environmental risks both within the supported living environment and in the wider community. They remained alert to how the person's behaviours could be affected by their surroundings and adjusted support accordingly. This included planning safe transitions in and out of the home, maintaining awareness of potential risks from objects or other people in public spaces, and ensuring clear strategies were in place to reduce the likelihood of harm. Staff told us they reported any environmental concerns promptly so action could be taken to maintain a safe living space.

Records and risk assessments reflected environmental considerations and were updated to ensure the environment remained safe and appropriate to the person’s needs. Care plans contained Personal Emergency Evacuation Plans (PEEPS) detailing the person’s 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 the person’s needs. Rotas demonstrated full shift coverage, and staff were deployed in line with person’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.

The person was 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.”

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. Records we saw confirmed what we were told.

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 and confirmed current infection prevention guidance and used personal protective equipment (PPE) to reduce the risk of cross‑infection.

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.

Records showed as required (PRN) medicines were used appropriately and only, when necessary, with staff documenting the rationale for use and the outcome following administration. Staff were trained in medicines management and assessed as competent before administering any medication.