Rapid Improvement Care Agency

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 newly registered service. This key question has been rated 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.

This service scored 62 (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 learning lessons.

The provider had failed to identify or address all the issues we found at this assessment in relation to the safe management of medicines, staff recruitment and training, end of life care, reporting incidents, record keeping and access, and analysing the outcome of audits and feedback to develop action plans to drive improvement. The registered manager told us they were aware they needed to develop a more effective and proactive approach to monitoring and continuously improving the quality and safety of their community care at home services.

People were encouraged and supported to raise safety concerns with the managers and staff. Systems were in place to support staff to report and record safety concerns and events when they arose. Any safety concerns or incidents that did occur were investigated.

The provider worked with people 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.

Managers and staff gathered information about people’s individual needs and wishes, and risks to their safety, prior to people receiving a supported living service from this provider. This information was used to develop person-centred care and risk management plans. These were shared with staff to help them provide safe and appropriate care to people from the moment they started residing in supported living accommodation run by this provider.

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.

People told us they or their relative felt safe with their regular carers. One person said, “I feel safe with my regular carers.” Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. A member of staff told us, “I make sure people are safeguarded by following the company’s safeguarding policies and procedures at all times. If I have any concerns, I report them immediately to my line manager or safeguarding lead and complete the appropriate incident or safeguarding forms.”

Managers worked proactively with the relevant community-based care professionals and agencies, when a concern was raised, and took appropriate action to safeguard people from further risk. A community-based care professional told us, “Managers and staff have dealt with allegations of abuse and neglect professionally and focused on maintaining the safety and wellbeing of my client, and co-operated with safeguarding inquiries in a transparent manner.”

The provider was working within the principles of the Mental Capacity Act 2005 (MCA). Staff understood people’s capacity to make decisions about their care and support using people’s preferred method of communication. Managers and staff had received Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Systems were in place to ensure risks people might face were routinely assessed, monitored and reviewed. People’s care records contained sufficiently detailed information for staff to follow. This ensured risks people might face were mitigated, so people remained safe when taking part in activities of daily life. A community-based care professional told us, “Staff have a good understanding of the risks my client faces. There is a detailed positive behaviour support plan in place for them which staff apply to reduce this assessed risk. They have updated my client’s risk assessments following incidents of concern to ensure that my client remains safe.” Staff were visibly present, attentive and aware of people’s whereabouts during our onsite visits to the supported living schemes.

Managers and staff were fully aware of the potential risks people might face and the steps they needed to take to reduce or safely manage them. Staff described how they balanced risk with independence, enabling people to undertake tasks for themselves whilst remaining safe. Risk assessments and management plans were reviewed at regular intervals and updated according to reflect any changes in people’s needs.

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

People told us they felt safe and comfortable residing in their supported living accommodation. The accommodation was kept free from unnecessary slip or trip hazards and obstacles which enabled people to move safely around their home. Detailed environmental risk assessments had been conducted on each supported living accommodation to ensure people lived in a safe place.

The Housing Provider responsible for the supported living schemes maintained and services safety systems and equipment. This ensured the properties they owned remained in a good state of repair and safe place for people to live and work in

The office-based managers and supervisors routinely conducted in-person monitoring home visits to help them identify and mitigate any potential environmental health and safety risks.

Staff told us they had clear guidelines available to help them deal with emergencies, including up to date fire safety risk assessments for their supported living accommodation and individualised plans to help them evacuate people in the event of a fire.

The provider ensured staffs home care call visits were well coordinated but they did not always follow safe staff recruitment practices or ensure staff were suitably qualified and skilled.

The provider followed safe recruitment practices and only suitable staff were employed to work as home care workers. However, we received mixed comments from community-based professionals in relation to the providers recruitment of staff to work in their supported living services. One community-based care professional told us we checked the providers staff recruitment practices as part of our own quality monitoring visits and found some gaps in pre-employment checks they should, have conducted before they allowed staff to start working for them.

We found no evidence that people had been harmed as a direct result of these staff recruitment issues, but it had placed people at risk of harm. We discussed this with the managers at the time of our assessment who confirmed all the relevant pre-employment checks had now been obtained.

Staff received a mixture of e-learning and in-person practical and theoretical training and competency-based assessments. However, staff training was not always being refreshed at regular enough intervals to ensure their knowledge and skills always remained up to date and relevant. For instance, the providers training matrix for the staff team working in their supported living services in one area indicated many staff were overdue refresher training in multiple areas of practice including, end of life care, mental capacity, medicines management, positive behavioural support and autism awareness. A relative told us, “The staff don’t know how to look after my [family member] properly because they are not well-trained.” A community-based care professional added, “There appears to be gaps in some staffs training which is not always being kept up to date as it should. We found a new member of staff who was supporting our client had not completed essential training in moving and handling, positive behaviour support, mental capacity and safe management of medicines.”

We found no evidence that people had been harmed as a direct result of these gaps in staff training, but it had placed people at risk of harm. We discussed these training issues with the managers at the time of our assessment who confirmed staff have now completed all the relevant training they needed or were booked to attend a suitable course by the end of July 2026.

Staff had ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might need. Staff had regular individual and group meetings with their line managers, supervisors and fellow co-workers. In addition, field supervisors routinely conducted monitoring visits to observe staff working practices to help them identify what staff did well and what they might do better. A member of staff said, “I receive regular supervision with my manager and attend some team meetings. I feel able to raise issues and to ask for support whenever I need it.”

People told us there were always enough staff working in each of the providers supported living services. Staff confirmed they were happy with the way their home visits or shifts were coordinated.

People received continuity of care from the same group of staff who were familiar with their personal care needs, wishes and daily routines. A community-based care professional told us, “The provider recognises how important it is for my client to receive care and support at home from a designated and stable staff team who are familiar with her wishes and daily routines.” Staff also described supporting the same individuals.

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.

The provider operated effective systems to help prevent and control infection. The supported living accommodation people lived in was kept clean. Staff had received relevant infection control and food hygiene training and had access to resources and equipment to help them reduce the risk of infections spreading. People told us staff followed good hygiene practices and used personal protective equipment (PPE) when needed. A relative told us, “They [staff] wear a mask and gloves when providing my [family member] with any personal care and are always very professional.” Staff reported they had consistent access to enough PPE. A staff member told us, “PPE is available when we need it, including gloves, masks, and hand sanitiser. We are encouraged to follow infection prevention and control procedures at all times.” Senior staff routinely observed staff working practices to check they were following safe infection control and hygiene practices when they supported people.

The provider did not make sure that medicines were safely managed because staff were not always suitably trained in the safe management of medicines and medicines records were not always appropriately maintained.

Medicines stocks and balances showed people consistently received their medicines as prescribed. Care records contained detailed guidance for staff about how people needed and preferred their prescribed medicines to be administered including, detailed risk assessments and protocols for the administration of prescribed routine and ‘as required’ medicines.

However, staff did not always follow relevant national guidelines around the recording of administered medicines. Medicines administration records [MAR] sheets were not always correctly signed by staff who had administered people their prescribed medicines. We found multiple gaps where staff had failed to sign a MAR sheet correctly after administering medicines. A community-based care professional told us, “Gaps on MAR charts had not been investigated.”

In addition, staff did not always clearly record the reason why they had administered ‘as required’ psychotropic medicines. This information is needed to help the provider and all the relevant community-based health and medical care professionals review any incident when staff have deemed it appropriate to administer ‘as required’ psychotropic medicines.

A few community-based care professionals told us staff were not always suitably e trained to safely administer medicines. One said, “Staff administering medication via an intrusive medical intervention had not received appropriate training from a health care professional. The team leader told us they had shown other staff how to do this despite not being trained to do this.” Another said this was an ongoing issue which the provider had failed to address in a timely manner despite it being flagged to the provider after it was identified following multiple quality monitoring visits conducted by an external social care agency.

We discussed this medicines training shortfall with the registered manager at the time of our assessment who acknowledged this had been an issue but was in the process of being rectified with staff booked to attend a suitable safe management of medicines training course by the end of June 2026.