Three C's Support

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 under the previous provider we rated this key question Good. At this assessment the rating has changed to 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 people’s person-centred care.

This service scored 34 (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. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Although there were some recorded accidents and incidents, including descriptions and actions taken, incidents continued to occur because there was no oversight or robust follow-up to ensure staff learned from them. The provider did not carry out any analysis of accidents and incidents to look for trends, themes or triggers. This meant staff were not always able to learn from incidents occurring across the service. A staff member told us, “Things aren’t being reported, recorded or acted upon. The team hasn’t taken ownership of issues, but we are working on that.”

The service had a comprehensive and detailed improvement plan; however some actions that directly impacted on the quality and safety of people’s support had not yet been implemented. For example, people’s support plans and risk assessments had not been updated, and an independent safeguarding review had not yet been commissioned despite the service improvement plan arising from a local authority audit that took place in April 2025.

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. There were multiple incidents that had not been reported to the local authority or the Care Quality Commission. Relatives gave mixed views about the support received. One relative said, “I don’t feel that [relative] is 100% safe It is the fear of not knowing what is going on there.” Another relative said, “I’m pleased with [relative] level of care and feel [relative] was having the best possible care to meet his very complex needs. A professional told us, “The provider does not currently meet the standard of ensuring safety from abuse and avoidable harm. Across multiple locations, we identified verified financial abuse, inappropriate staff conduct and serious safeguarding failures. These incidents reflect systemic weaknesses in safeguarding culture, supervision, and escalation protocols”. Another professional shared, “Some staff are aware of the signs, where and how to report however this varies between staff. I am not totally confident that all staff are able to pick up signs and how to report abuse both internally and externally – I know these staff had attended safeguarding training”. The provider’s approach to learning from safeguarding incidents was not robust. There was inconsistent information about which staff this was discussed with or what had been learnt or implemented to improve outcomes for 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. There were multiple incidents that had not been reported to the local authority or the Care Quality Commission. Relatives gave mixed views about the support received. One relative said, “I don’t feel that [relative] is 100% safe It is the fear of not knowing what is going on there.” Another relative said, “I’m pleased with [relative] level of care and feel [relative] was having the best possible care to meet his very complex needs. A professional told us, “The provider does not currently meet the standard of ensuring safety from abuse and avoidable harm. Across multiple locations, we identified verified financial abuse, inappropriate staff conduct and serious safeguarding failures. These incidents reflect systemic weaknesses in safeguarding culture, supervision, and escalation protocols”. Another professional shared, “Some staff are aware of the signs, where and how to report however this varies between staff. I am not totally confident that all staff are able to pick up signs and how to report abuse both internally and externally – I know these staff had attended safeguarding training”. The provider’s approach to learning from safeguarding incidents was not robust. There was inconsistent information about which staff this was discussed with or what had been learnt or implemented to improve outcomes for people.

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 did not have a system in place to facilitate people being involved to manage risks relating to their support. Risk assessments that we reviewed were out of date, contained old and superseded information and in some cases, were identical between people although their identified risks differed. For example, the ‘community risk assessment’ for two of the people who lived in one supported living home were identical, although their physical presentation and mobility differed. The strategies identified in the risk assessments to mitigate risks were the same.For some people, risk assessments did not clearly and thoroughly identify all of the risks relating to their support and there were not appropriate mitigation strategies in place to guide staff should these risks occur. Some people’s risk assessments were not reviewed after incidents had occurred, and strategies to guide staff were not updated based on what had been effective, and what hadn’t.

There was no indication people had been involved in the development of their risk assessments, nor were aware of them. Some people were not able to communicate verbally, and the provider had not taken steps to ensure they understood the risks relating to their support in ways they could understand.

Other people’s risk assessments were detailed, thorough and included updated information to guide staff to mitigate the identified risks. Some people were assessed as being at high risk of choking. We saw that they had guidelines developed by a Speech and Language Therapist that were followed by staff to reduce this risk.

Where people had health conditions that left them at significant risk, such as epilepsy, we saw their risk assessments had been developed with input from the appropriate health professionals, and we observed staff following their guidelines.

The format of risk assessments differed significantly between the supported living homes, and between risk assessments. There was different information included in these and they were not always clear, which could be confusing for staff.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The environment in some supported living homes was not a homely, welcoming place and communal areas such as lounges and bedrooms were not personalised. The provider did not ensure they were proactive in raising maintenance concerns and repair issues on people’s behalf.

A family member told us, “Their living conditions are inadequate, I think they are working with the housing provider to sort this but it’s not acceptable. Slates are falling off the roof. There has been a fridge in the hallway since April 2025, and I haven’t got a clue who’s that is. Choice needs to advocate better for them with landlords because there a lot of things wrong with the house.” Another family member said, “Yes, it is always tidy. The ceiling caved in for the 2nd time due to dodgy workmanship, it’s fixed now but it still looks damp in the dining room still. Management didn’t pull their weight initially but were very apologetic.”

We observed there were several maintenance issues within several of the supported living homes.

Although Choice Support, as the support provider and not the accommodation provider, were not always responsible for maintaining and ensuring the safety of the environment in which people lived, they had not always taken appropriate action when issues were identified nor had they appropriately advocated on behalf of the people using services.

People's communal areas looked tired and in need of refreshing and/or refurbishment, e.g. paint scrapes on walls, and chairs needing replaced. We noted repeated cracks and water damage to some ceilings and walls. Some soft furnishings were visibly dirty, and some chairs had tears in the fabric which increased the risk of infections spreading due to these being difficult to effectively clean. These were brought to the staff attention and were informed that landlords to some of the properties were undertaking a programme of maintenance and repairs which included redecoration. A staff member told us that the bathtub in one of the supported living settings we visited had not a side wall for years, however this had not been reported to the housing association and seemingly no one had noticed it. It was unsightly and contributed to the feeling of neglect of the supported living home. In one supported living setting we visited, maintenance works were taking place including painting, replacing the flooring and installing a new kitchen. However, a risk assessment had not been developed and one person spent most of their time in the kitchen where works were taking place. During our visit, we observed the person fall as the kitchen was crowded and there were tools and materials lying about. There were no mitigation strategies in place, nor had it been explained to the person that the kitchen would be a dangerous place while the works were ongoing and support provided to find alternative places for them to spend their time. The supported living setting was also cluttered, messy and dirty. Staff did not support people to live in a clean, safe home. In another supported living setting the lift was out of order for months at a time. All four of the people who lived on the first floor were wheelchair users and relied on the lift to leave the property. The provider did not take effective, timely action to ensure that the landlord was aware of the scale and impact of the problem, which meant that they weren’t able to leave their home for eight months. They did not undertake any activities outside of the home, or go on holidays due to this. Other supported living settings we visited were safer and cleaner. Staff told us they were responsible for supporting people to ensure they lived in a clean, safe home and we saw that oversight of this by the service managers/ team leaders differed from home to home. Some people relied on equipment to ensure they were supported safely, for example hoists, sleep systems and enteral feeding pumps. We saw these were clean, well-maintained and checked according to the manufacturers’ recommended schedule. We saw that staff had sought replacements from the appropriate agencies when these were wearing or in need of repair.

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.

Health professionals, family members and staff raised concerns about the service’s lack of sufficient staff, which left people without sufficient support to access the community. This meant people could not go out as they were restricted because of the staffing levels. As a result, there was a risk that people were not being supported in a way that promoted meaningful outcomes or enabled them to achieve their personal goals.A professional told us, “There are insufficient staff to support and keep the residents safe and people are restricted in accessing their local community because there were insufficient staff to accompany people individually or in a group. This I have raised this several times and get told we are reviewing the staffing levels."

Comments from relatives, “They’ve had problems getting hold of staff, but they don’t seem to stay. I think staff are thin on the ground though.”

Another relative told us, “They did say they were short staffed,”

Another relative said, “I worry about the ratio of help, even though the staff members are in the building I don’t think it’s fair how much support some people get compared to others.”

And another relative explained, “There is such a turnover of staff but the ones there at the moment are brilliant as are the ones who were there before.”

There were not enough staff deployed to ensure people received safe, high-quality support that met their needs and preferences. There were not enough frontline managers within the staffing structure to ensure competent, effective oversight of the support people received. The registered manager told us they did not have a formal, structured mechanism to determine the number of staff the service needed. The interim service manager told us, “The registered manager was overstretched so we are recruiting for more managers. It is a long-term project.”

In some supported living settings, support staff worked excessive hours and were not provided with appropriate rest periods in between shifts. Rotas showed that one support worker routinely worked 48 hours at a time (two 24-hour shifts in a row, including sleep-ins) without a scheduled break. In one week, they worked three sleep-in shifts (72 hours) without a break. They told us they were usually woken during a sleep-in, as people needed support through the night. They said, “With three people to support it can be a lot. [Person] needs a lot of attention, they can get angry and need help to calm down, and [another person] needs a lot of support to go to the toilet. Plus [staff] do all of the cooking and cleaning. It is hard by yourself.”

In another supported living setting, staff routinely worked more than double their contracted hours, between 63 and 83 hours per week; for some staff, this meant working seven days per week.

Staff told us about how this affected their morale and well-being. One staff member told us, “You can’t have a life outside of work, there isn’t time.” Another support worker said, “I do it because I care about the people we support but Choice Support doesn’t seem to care about our [staff] wellbeing.”

Staff told us about how staffing had been reduced in some supported livings settings since the provider had changed. One support worker said, “There used to be two team leaders, for the three flats. Now there is one for three flats. [The team leader] doesn’t have enough time to do the admin tasks they need to do, as they step in to support people when there are shortages. We are always short staffed.”

There was a high turnover of managers which affected continuity of people’s support and meant that required updates and checks on people’s support had not taken place. This left people at significant risk of abuse and avoidable harm as the oversight required for a safe, high-quality service was not in place or effective.

There weren’t enough staff deployed to ensure that people were supported to undertake stimulating activities of their choice, or that they experienced a good quality of life. We saw that one person was left alone in their bedroom looking at the ceiling with no sensory stimulation while they were feeding using an enteral feeding machine. When we drew this to the team leader’s attention, they turned on the radio. The person’s support plan stated they liked to have their meals in the living room next to their sensory bubble tube and in the company of their flatmates while they were feeding (which takes six hours per day) but the team leader told us there weren’t enough staff on shift to support the person to be in the living room.

In some supported living settings, there were enough staff and the staff teams were stable and consistent. People had 1:1 support to undertake activities of their choice, and staff were rostered on to ensure there was flexibility in the rota for people to be able to attend appointments safely.

We reviewed the personal emergency evacuation plans (PEEPs) for people living in the services we visited. PEEPs contained information about how each person would be supported in the event of an emergency, such as a fire. Some people required assistance from two staff to be safely evacuated out of the building however the service rota confirmed there was one waking night staff rostered on at night. We were therefore not assured that people would be safely evacuated in the event of a fire at night. We did not see fire drills undertake at night.

Staff were recruited through a robust process which included them providing evidence of their performance in their previous role, their right to work in the UK and their fitness for the role. Prospective staff underwent a Disclosure and Barring Service Check (DBS) prior to commencing work to ensure they were suitable to work in this type of setting.

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.

Infection Prevention and Control and environment audits had not been effective as during the inspection we observed that many of the properties we visited were unclean and infection prevention and control practices varied significantly between the supported living settings; due to the lack of oversight from consistent and competent frontline managers, it was up to support staff to devise cleaning schedules according to their own personal preferences.

Personal protective equipment (PPE) supplies were not always available across each of the supported living settings.

We found that food safety and health and safety standards were not embedded or part of staff practices or checks.

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.

Staff received training to manage medicines safely and were assessed annually to ensure they remained competent. Additional training was provided so staff could meet the needs of people requiring support with specialist medicines.

Staff carried out medicines’ reconciliation (the process of checking that the list of medicines a client is taking is accurate and discussed any discrepancies with the pharmacy).

Medicines (including controlled drugs) were stored safely and securely. Staff monitored storage temperatures, and these were within the required range. Staff recorded dates of opening on medicines to ensure they were used within their expiry date. Staff recorded and returned unwanted and expired medicines to the pharmacy for safe disposal.

People received their medicines as prescribed. Staff recorded when medicines were given. Staff knew how to support people with their topical medicines However, guidance for where to apply the medicines was not always available. This meant there was a risk that people may have their topical medicines applied consistently. We advised the provider to review this.

Staff understood the importance of monitoring constipation in people living with a learning disability and knew when to seek medical advice. However, staff did not always record enough detail on bowel charts for people at risk of constipation. This meant that issues may not be identified in a timely way and people may become unwell. During the inspection, the provider took action to address this.

People’s care plans included information for staff to know how to support them appropriately. For example, how they liked to take their medicines or how to manage seizures and seek medical advice. Staff knew when to give ‘when required’ medicines (PRN). However, written information lacked detail to support individuals in a person-centred way. This meant that people may not receive their medicines appropriately when regular staff were unavailable.

Staff reported medicines incidents and action was taken to prevent any errors reoccurring. Staff completed medicines audits regularly which identified some areas that required improvement. Action was taken to rectify issues, but the audits had not identified or addressed the issues that we identified in relation to people medicines.

Whilst staff received patient safety alerts, they did not record how the alerts were managed. We were therefore not assured that people were kept safe from identified risks. We advised the provider to review this.