West Hampshire DCA

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

This service scored 69 (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 support improvements in practice.

Staff demonstrated a clear understanding of how to record and escalate incidents, using established systems such as paper and electronic reporting systems, with reporting completed promptly and in line with policy. They described confidence in raising concerns and were aware of both internal escalation routes through management and external options, including safeguarding teams, the local authority and CQC. Staff highlighted the importance of clear, neutral recording and reflective practice, helping to ensure incidents were accurately recorded and lessons were learned.

Incidents were investigated thoroughly, with management oversight and regular opportunities for debrief. Staff reported that they received feedback through house meetings, individual discussions and check-ins, which supported reflection and learning. Where needed, additional training and guidance, such as Positive Behaviour Support (PBS) input, was provided to improve responses to incidents. Staff gave examples of how ongoing review and escalation of concerns led to identifying underlying causes, including the impact of medication changes, resulting in improved outcomes for people. This demonstrated a learning culture where staff felt listened to and lessons were used to drive improvements in care and safety.

The provider worked with people, their families 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.

Relatives described being actively involved when their loved ones moved in, with 1 noting they were “very much involved in choosing the company and property” and another that they were “consulted about all aspects of the move.”

Hospital passports were in place to support safe and effective communication during people’s transitions between services, helping to maintain continuity of care.

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.

The service shared and investigated concerns appropriately and reported these to the relevant agencies.

Relatives felt people were safe. Comments from relatives included, “My sister is 100% safe, she is safe because the staff are very good and know her well” and another relative told us, “Yes I am happy with all aspects of safety, I have no worries.”

Staff had a clear understanding of the types and signs of abuse and how to report any concerns.

The provider did not always work effectively with people to understand and manage risks. Improvements were needed to ensure care was consistently safe, well-documented and supported people to do the things that mattered to them.

Risk assessments had not always been reviewed in line with the provider’s own guidance, meaning records could not be relied upon to consistently reflect people’s current risks or needs. This reduced management oversight and increased the risk that staff, particularly new or unfamiliar staff, may not have access to clear, up-to-date guidance on how to safely support people. Documentation also did not consistently evidence how people and their relatives were involved in decisions about managing risk.

Although this presented a potential risk, staff demonstrated a good understanding of people’s individual needs and risks in practice and were able to describe how they supported people to remain safe while maintaining their independence. Relatives also gave positive feedback about their involvement, with one saying, “We discuss openly any arrangements concerning where my brother is going and potential risks,” and another stating, “We are consulted about potential risks involving my son, for example traffic risks and support in the community.”

However, the reliance on staff knowledge, rather than consistently accurate and up-to-date records, meant systems were not sufficiently robust to ensure safe and consistent risk management. Overall, improvements were required to ensure risk assessments were regularly reviewed, clearly recorded, and supported effective oversight and safe, person-centred care.

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

Where environmental concerns related to the property itself were identified, these were clearly reported to the landlord, who held responsibility for maintaining and addressing issues within the building. This ensured that any structural or environmental risks were escalated appropriately and managed through the correct channels.

Additionally, equipment used to support people’s needs were managed and maintained through the relevant external providers. For example, when an individual’s epilepsy bed sensor was identified as not working during a routine daily epilepsy monitoring check, staff took immediate action. While awaiting resolution, staff implemented additional overnight safety checks to monitor the individual and reduce risk. This demonstrated a clear understanding of responsibilities, with appropriate escalation routes for both environmental issues and specialist care equipment, alongside a proactive approach to maintaining people’s safety.

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.

Staff told us they received regular supervision and felt well supported, with opportunities to discuss performance, wellbeing, training needs and any concerns. One staff member told us, “They go through everything, how are you finding it, anything you need to improve on, long term goals and any support you need.” Other staff described these sessions as a chance to raise issues; discuss the people they support and identify any additional support required.

Safe recruitment processes were in place. This included right to work information and disclosure and barring (DBS) checks. Staff had completed ‘Towards Understanding Autism and Learning Disabilities’ training, strengthening their knowledge and confidence in supporting people with learning disabilities and autistic people

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 home environments were visibly clean. Staff had completed infection prevention and control training. Personal protective equipment (PPE) and handwashing facilities were available in people’s homes.

The provider had systems in place to support the safe management of medicines, and people received their prescribed medicines as intended. However, medicines practices were not always implemented consistently or fully aligned with best practice, and records did not always support safe or effective oversight.

Medicines were stored securely, and core processes such as Medicines Administration Records (MAR) and temperature monitoring were in place. However, we identified specific gaps in medicines management. Records were not always complete or up to date, including missing opening dates and unclear documentation of topical medicines. For example, one person prescribed Ibugel did not have a corresponding body map to guide staff on where it should be applied, increasing the risk that it may not be used in line with prescriber instructions.

Some key documents were outdated or incomplete, which reduced the effectiveness of guidance for staff and oversight by the provider. For example, PRN (as required) protocols had not been regularly reviewed, staff signature sheets included staff who were no longer employed at the service, and records relating to medicines taken on holidays or trips contained gaps, including missing information on quantities returned, times of return, and staff signatures.

Systems for monitoring medicines were in place but had not consistently identified or addressed these issues. Whilst no harm had occurred, these gaps increased the risk of medicines not being managed safely and demonstrated the need for more robust and effective oversight to ensure medicines practices remain safe and in line with best practice.