East 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.

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 legal regulation in relation to safe care and treatment, including management of risk, safe environments, and medicines.

This service scored 56 (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. Incidents and accidents had been reported and investigated appropriately. Lessons learnt were shared with staff. One staff member told us, “Yes they are investigated properly and effectively, when something happens, we discuss the way forward and how to prevent it from recurring.” A relative told us “I have raised some serious concerns in recent months. These were addressed and there are currently some improvements that I have noted and am pleased about.”

The provider did not always have effective systems or pathways in place to support safe transitions. Staff told us they planned to move a person to a downstairs bedroom due to the risk posed by stairs; however, no formal transition plan had been developed to manage this safely or to consult with the people already living in the flat who would be affected by the move. Staff also reported receiving a care plan when someone moved in but were not aware of any structured transition processes for internal or external moves. The absence of clear procedures increased the risk of uncoordinated care, unclear responsibilities and gaps in risk management.

People had hospital passports, supporting safer information‑sharing with health services.

The provider had safeguarding systems in place. Identified safeguarding concerns were shared appropriately in a timely manner. However, ongoing risks relating to a person’s use of the stairs had not been recognised or reported as a concern in line with safeguarding procedures, meaning a potential risk of harm had not been escalated.

We found restrictive practices in place such as locked fridges without the required supporting documentation, such as consent forms and detailed mental capacity assessments. This meant the service could not evidence that these decisions were lawful, necessary, proportionate, or in the person’s best interests. Some existing capacity assessments lacked detail about the information shared and discussions held.

Staff had access to relevant policies, including safeguarding, equality and human rights, and anti‑bullying and harassment. Staff understood the signs of abuse and how to report concerns, although there was mixed understanding of restrictive practices. Staff had completed safeguarding training. Families told us their family members felt safe.

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 had identified that a person was at increased risk when using the stairs. However, no meaningful action had been taken to escalate this concern or update the person’s risk assessment to reflect the severity of this risk. This placed the person at continued and avoidable risk of harm.

Personal Emergency Evacuation Plans (PEEPs) contained contradictory and unsafe guidance. For example, some plans referred to a ‘stay‑put’ strategy agreed with the fire service, while simultaneously providing information on evacuation procedures. This inconsistency had the potential to cause confusion, particularly for new or unfamiliar staff, and increased the likelihood of unsafe decision making during an emergency. In addition, PEEPs did not specify evacuation points, meaning staff did not have clear, actionable instructions to follow to ensure people reached a safe location.

Some staff checks for mobility equipment used by people were missing, meaning staff could not be confident that equipment essential for people’s mobility and safety was in good working order. This exposed people to avoidable harm, including the risk of falls or injury from unsafe or poorly maintained equipment.

Other risk assessments contained outdated or inaccurate information. For example, one assessment stated a person had access to a mobility car that had been returned a few months ago, while another referenced a mobility aid that was no longer in use. This meant staff were relying on information that did not reflect people’s current needs or circumstances.

We acknowledge some positive examples of community access, independence and positive risk taking; however, these were not consistently supported by effective risk management.

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.

There was a large broken table in the garden that people had access to, and the decking around the summer house had large gaps, broken sections and loose, moveable boards. Despite this, the provider’s visual inspection checklist for the building, dated 29 January 2026, did not identify or record these concerns and this information was not included in the environmental risk assessment. These hazards increased the risk of people tripping, slipping or falling when accessing the communal outdoor area.

The rear door leading to the communal garden allowed free exit but automatically locked when closed, meaning individuals required a key to re‑enter their building. This presented a risk of people being unable to regain access to their own home without staff support.

Fire evacuation records did not detail who had participated in these, as advised by the fire services. Without clearly recording who was involved, we were not assured that all individuals, particularly those with additional support needs had been included in evacuation practice or that staff had tested how to assist them safely from their own accommodation. As a result, people may not respond safely or promptly in an actual fire, increasing the likelihood of avoidable harm.

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 had a thorough induction when joining the service and received ongoing supervision and development opportunities. The provider ensured staff received training relevant to their role. Safe recruitment processes were in place. This included right to work information, evidence of previous conduct and disclosure and barring (DBS) checks. Staff had completed 'Towards Understanding Autism and Learning Disabilities' training,helping strengthen their knowledge and confidence in supporting people appropriately.

The provider assessed and managed the risk of infection. People's home environments and equipment were visibly clean. Staff had completed infection prevention and control training and had access to relevant guidance. Personal protective equipment (PPE) and handwashing facilities were available in people’s homes.

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.

Risk assessments for the use of emollients were in place; however, these were not consistently completed or aligned across records. Some assessments did not clearly identify the person throughout and references to staff awareness and active risk management were not supported by contemporaneous evidence. When cross‑referenced with individual person‑centred fire risk assessments, emollient use was not included and recorded as requiring no further consideration. This reduced assurance that known risks associated with the use of emollients, particularly paraffin‑based products which can increase the risk of fire when absorbed into clothing or bedding, were fully assessed and managed.

Body maps were available for the application of topical medicines; however, some lacked implementation or review dates, and documentation did not always clearly link creams and body maps to the individual.

PRN (as‑required) protocols were in place and provided appropriate guidance for staff. Staff had received medicines training and had completed medicine administration competencies.