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 we rated this key question inadequate. 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 provider was in breach of regulation 11 and regulation 12. People did not always consent to their care and were not always involved in decisions about their care and support. The provider had improved some risk assessments, however risk-management systems remained inconsistent.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always recognise, report or escalate safety concerns appropriately, which limited opportunities to identify risks, investigate incidents and embed learning.

The provider had re-established its incident reporting systems and processes to support the identification of themes, trends and patterns relating to safety events. However, these were not yet fully implemented and had not resulted in consistent reporting practices across the service. Staff recorded incidents on the electronic system and managers reviewed individual events, but there was limited evidence the provider analysed these collectively to identify trends or opportunities for improvement.

Although we saw examples of incident and accident audits, staff did not always report incidents in line with the provider's procedures. One staff member told us a person had hit them with a walking stick. They emailed the local authority but did not complete an incident form. A person with multiple needs had injured a member of staff during personal care. Staff had not formally reported this, and the provider's audits had not identified it, so the provider missed opportunities to identify triggers and implement safe management strategies.

Records of another incident, in which a person set a microwave on fire, recommended updates to their support plan. Staff had not amended the plan or reviewed the environmental risk assessment, although they had removed the microwave and supported the person to use the kitchen safely. Lessons learned sections contained templated wording rather than analysis of the event.

Managers recognised the shortfall and told us they would strengthen incident reporting with the staff team.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care, and did not always make sure there was continuity of care when people moved between services.

People had risk assessments in place, but some were more detailed than others, so it was not always clear how staff managed risks in practice. There was limited evidence to demonstrate how people were involved in developing or reviewing their own risk assessments, which reduced opportunities for people to understand their risks and make informed choices about their care.

People had hospital passports containing appropriate information about their communication, health conditions, medicines and support needs to keep them safe during hospital admissions.

However, one person's electronic care record indicated they were for resuscitation while other parts of their care plan suggested they were not. Their hospital discharge letter from November 2025 recorded that hospital staff were unclear whether a do not attempt resuscitation decision should continue in the community, and the provider had not resolved this. This meant staff risked acting on inaccurate information in an emergency. When we raised this issue, staff confirmed no DNACPR form was in place, removed the conflicting references and agreed to discuss the matter with the person's GP.

Staff made referrals to health professionals when people's needs changed, including to speech and language therapy where they identified choking risks, and specialist teams supported the development of people's behaviour support plans. People and staff knew how to raise and communicate concerns.

The provider did not always concentrate on protecting people's right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and did not always share concerns quickly and appropriately.

We found some incidents which met the threshold for a safeguarding referral which had not been notified to CQC as required. The former manager had not identified a number of incidents as reportable. Incidents involving one person were recorded on the provider's system as not meeting notification criteria. This limited external oversight and meant we could not be assured the provider took appropriate action to safeguard people or mitigate future risks. We found one person's care records did not detail how a known risk could be mitigated.

Staff held an anticipatory management plan for one person dated February 2024. A health professional's discharge report stated the plan had been reviewed in November 2025 and that the reviewed version should be shared with emergency services. The version held by staff therefore differed from the current plan, which meant staff risked sharing out-of-date crisis information.

Since our last assessment, the provider introduced systems to monitor approved and pending community Deprivation of Liberty Safeguards (c-DoLS) applications, and a tracker showed the position for each person. Staff assessed people's capacity and recorded best interests’ decisions involving the appropriate people. A board-level safeguarding committee reviewed incidents, accidents and safeguarding concerns and the actions taken.

The provider ensured staff received safeguarding training, and staff understood how to escalate and report concerns. The provider made safeguarding referrals appropriately and supported people to raise concerns. Arrangements to safeguard people's finances had improved. Where people were at greater risk of financial abuse, the provider arranged additional verification with the person's bank, checked finances weekly and audited these checks monthly.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that was safe, supportive and enabled people to do the things that mattered to them.

The provider had improved how staff understood and managed some risks with people. Staff knew people well and, in practice, often supported them safely. However, the provider had not yet consistently translated this knowledge into complete and up-to-date risk assessments and support plans across all settings.

However, staff had not completed the risk assessment sections of the electronic care system. Risk information was recorded within support planning sections, and the records did not clearly demonstrate that the provider had considered a comprehensive range of risks for each person. For one person with identified high-risk areas, including vulnerability in the community, numerous risk assessment templates remained blank. A further known risk had been raised with the person by their housing officer, but the support plan did not identify this risk or set out how staff should manage it. Staff could not locate the person's community access guidelines on the system.

Where people experienced heightened emotional distress or behaviours that could place themselves or others at risk, staff had limited written guidance. A consistent staff team who knew people well partly reduced this risk. However, replacement staff covering absence or annual leave might not have had enough information to support people safely.

One person wore an emergency pendant, but their support plan did not refer to it and no risk assessment covered its use. Staff were unclear why the person had the pendant.

We observed staff supporting people in line with speech and language therapy guidance at mealtimes. Staff described people's risks and the measures used to reduce them. Staff told us they felt able to raise concerns with managers, who responded and provided guidance. We also saw evidence that staff made referrals to healthcare professionals when needed.

The provider had improved risk assessments in some areas. For example, it had assessed risks relating to epilepsy and constipation and recorded appropriate management strategies. The provider needed further time to apply this improved approach consistently, embed it within staff practice and sustain it across all settings.

The provider detected and controlled most potential risks in the care environment and made sure equipment, facilities and technology supported the delivery of safe care but did not always keep environmental risk assessments up to date.

At one home, the general risk assessment was overdue for review, with a review date of May 2025, and staff had not reviewed it after a fire incident in February 2026. Another home had an infection control risk assessment but no general environmental risk assessment. The provider also had no lone-working risk assessment in place. These findings showed that the provider had not yet consistently embedded its approach to environmental risk management across settings.

Since the last assessment, the homes we visited were clean, well maintained and personalised. The provider regularly tested fire alarms and emergency lighting completed water temperature checks and legionella testing, and maintained gas safety certificates and electrical and portable appliance testing records.

The provider carried out fire drills regularly. In one setting, it increased these from six-monthly to every two months, and in the Hackney settings it completed drills at different times of the day and night. People had individual personal emergency evacuation plans. A fire assessor had recently visited one home. Staff reported an identified repair to the landlord, and the landlord completed it during our visit. Repair logs showed staff reported maintenance issues and recorded when they had been addressed. The provider also arranged regular servicing of equipment used to support people, including wheelchairs.

The provider operated a Housing Advocate programme. A staff member audited property safety and followed up maintenance and safety issues with landlords. This had resulted in essential maintenance work taking place in two settings during our visit. These arrangements showed improvement, but the provider needed further time to embed a consistent approach to environmental risk management and demonstrate that improvements were sustained across all settings.

The provider did not always make sure there were enough qualified, skilled and experienced staff deployed to keep people safe at all times.

During our visits, staffing levels during the day met people's needs and changed to reflect planned activities. Staff told us staffing levels were manageable, the team generally covered sickness, and agency staff were available in an emergency. Rotas showed staff no longer worked excessive hours and contingency arrangements were in place. Staff worked across services to reduce the risk of closed cultures developing, and people with significant support needs had a core team of trained staff supporting them.

However, one setting had a single sleeping night staff member despite the provider having identified risks relating to one person at night-time. The person's risk management actions stated staff should monitor them, but no waking staff were available to do so.

The provider did not have a dependency tool or similar mechanism, but used people's individual care packages to inform staffing levels and told us current numbers met people's needs. We found some people may not have had sufficient commissioned support hours to fully meet their identified needs. The provider told us local authority care packages determined support hours and that they had raised concerns with the relevant local authority teams, but no additional hours had been agreed at the time of our assessment.

People's opportunities to take part in activities outside their home were not always supported by the staffing arrangements in place. One relative told us, “I have observed one person on duty on a Sunday afternoon, with four people. At the moment there is only one part time worker who is a driver. I have been assured this will be sorted.”

Staff completed an induction, mandatory training and the Care Certificate where required, and the provider recruited staff safely with appropriate pre-employment checks. Staff received regular supervision and appraisal and told us the training gave them the skills they needed. One leader told us, "We have had to use some agency staff which isn't ideal. It's better if there is a familiar face for the [people we support]."

The provider assessed and managed the risk of infection, detected and controlled the risk of it spreading, and supported people to live in clean environments.

Staff completed infection control training and demonstrated a good understanding of infection prevention principles. Staff described the measures they took to reduce the spread of infection if a person became unwell, including supporting the person to reduce contact with others and using personal protective equipment. We observed staff using PPE appropriately and in line with current guidance. One person told us, "They [staff] keep this place very clean."

Appropriate policies and procedures supported effective infection prevention and control practice. The homes we visited were clean, well maintained and free from unpleasant odours. Cleaning schedules identified daily and periodic deep-cleaning tasks and staff signed them off, and a contract cleaner carried out a thorough clean during one visit. Staff stored COSHH products securely while keeping them accessible.

The provider monitored infection prevention and control practice through regular checks and audits, including observations of staff practice, to identify and address areas requiring improvement.

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.

At our last assessment, we were not assured that people always received their medicines as prescribed.

During this assessment we found some improvements had been made in this area. However, the Medicines Administration Records (MARs) we reviewed contained gaps for medicines taken ‘when required’. People's profile pages and medicines sheets were not always accurate or up to date with current medicines or changes to them. They were not person-centred and did not provide sufficient information on how medicines were to be administered safely, or how to manage the condition for which they were prescribed.

When people were prescribed topical preparations, such as gels, creams or emollient creams, body maps were not in place and therefore did not provide staff with guidance on where the creams were to be applied. This increased the risk of inconsistent practice and did not support staff to manage, administer and record topical medicines safely and effectively. In addition, there were no risk assessments in place for people prescribed flammable emollients.

Medicines audits were completed weekly and monthly. The most recent comprehensive audit had not been effective at highlighting some of the issues found during our assessment.

Medicines were stored securely in medicines cabinets and there was good stock availability. All medicines in use were within their expiry dates and stock counts were accurate.

Training records were up to date for all staff administering medicines and competency assessments had also been completed for all staff.