Archived: Optimum Supported Housing Limited

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 at the new registered address. This key question has been rated Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safeguarding, safe care and treatment and staffing.

This service scored 28 (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 did not have a proactive and positive culture of safety based on openness and honesty. The provider did not have a robust system in place to review incidents and accidents and ensure appropriate action was taken. The incident log detailed one person had a fall in February 2025, but the exact date was recorded as unknown. The actions detailed ‘add additional measures to keep them safe’. There was no other information as to what these additional measures were and how this would be monitored. Leaders had not reviewed the person’s daily notes and had not spoken to staff to gain an account of the incident. Another incident was recorded on 25 April 2025 where a person was very unwell and vomiting. This had not been reviewed by the provider and no other information was detailed as to what medical assistance was sought if any or what action needed to be taken following the incident, such as referrals to other health professionals.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. The provider told us the majority of the staff team were agency staff. The provider told us they felt this gave a better of continuity of staff, however we found this not to be the case. We found that not all people had continuity of care from regular staff members. This consistency helps people feel secure, reduces anxiety, and allows them to develop stronger relationships with staff, ultimately improving their overall well-being and quality of life. People’s care and support was not coordinated, and the provider had not ensured that risks relating to people’s care journeys had been considered, for example, ensuring suitable training is in place for staff prior to staff supporting people.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The provider told us they did not have a safeguarding log as there had not been any safeguarding concerns; however, we found this was not the case. The provider had failed to ensure people were not subjected to unlawful physical restraint. The provider told us no one needed any physical interventions, however when we spoke to staff they described how they ‘held’ people and ‘hugged’ if they were distressed and would not let go if the person told them to. Unlawful restraint that is unnecessary or disproportionate is a form of physical abuse and may be considered a safeguarding concern. The provider had not ensured that people who were at risk of self-neglect had measures in place to safeguard them. One person’s daily notes identified they often refused their personal care; however, the provider did not have guidance in place to inform staff on how to support this person if they were neglecting themselves.

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 not ensured risks to people’s health were well managed and there was a lack of effective guidance in place to inform staff how to support people safely. For example, some people were at risk of constipation and there was no guidance in place for staff to follow to ensure staff could support people to manage this and seek medical assistance if required. People who had epilepsy did not have effective care and support plans in place. There was a lack of information for staff to follow regarding seizures and how to support people if they had a seizure either in their home or in the community. In addition, staff we spoke with did not have the knowledge to support people safely with epilepsy. People who needed support when they were anxious or distressed did not have effective guidance in place for staff. For example, 1 person could get anxious during personal care and display physical behaviours towards staff. However, there was no information in their care plan to guide staff on how to support them. One person had been diagnosed with multiple mental health disorders. There was no information or guidance in their care plan on how staff could support the person on a day to day basis or if they reached a mental health crisis.

The provider did not always detect and control potential risks in the care environment. The provider failed to ensure risks relating to the environment were effective. Information in people’s care plans around environmental risks were generic and not person specific. Care plans detailed for the person to ‘live in a safe well-maintained environment’ but no other information was detailed on how staff can support people to achieve this. We were not assured that people were being supported to maintain a safe environment.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. The provider failed to ensure staff were recruited safely. We reviewed staff files which had missing information, such as gaps in employment history and interview questions. The provider failed to ensure they completed checks on agency staff, this included making sure they had the relevant training. The provider failed to make sure all staff had completed the training they needed to support people safely. We identified 2 staff were on the rotas but were not on the training matrix. The provider could not evidence that these staff had completed training prior to supporting people and therefore we could not be assured that had the skills and competence to support people safely.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The provider had not ensured that all staff had completed IPC training, some staff were not on the training matrix and therefore we could not be assured that all staff had completed IPC training.

Information in people’s care plans was basic around IPC and did not contain detailed information for staff on how to support people with risks relating to IPC. For example, one person’s care plan detailed they needed 1-1 support with cleaning products, but there was no other information.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider failed to ensure that medicines were managed safely. We reviewed medication administration records (MAR) that were inaccurate and contained information that was false. The provider told us that a senior staff member would video call staff and whilst they administer medicines, the staff would then sign the medicine record with the senior staff members name, even though they were not present when they administered the medicines. The provider told us this was because staff were not competent to administer medicines. Signing for someone else creates a false record of who administered the medication.This makes it difficult to track medication errors, identify patterns of missed doses, or trace the source of any adverse reactions. The provider had also failed to ensure the guidance was in place for ‘as required’ medicines. People who were prescribed ‘as required’ medicines for distress and anxiety did not have robust guidance in place. One person’s care plan detailed staff should ‘pre-emptively administer’ a sedative medicine. The medicines had been administered on 6 occasions in June 2025 and staff had not clearly detailed why the medicines was administered. We could not be assured that staff were administering the medicine appropriately, safely or in line with STOMP guidance. STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines.