SeeAbility South Gloucestershire Support Service

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 type of supported living. 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Whilst there were systems to raise concerns and promote a culture of openness. There were examples where learning had not been taken from incidents, concerns or accidents. For example, there were some concerns about financial abuse where there was a theft of money. This happened on two subsequent occasions to the same person, which meant the service had not embedded good practice to make improvements around their financial procedures and thus protecting people.

A person raised concerns about a member of staff last year and their conduct towards them. Whilst we were told this was investigated, the same member of staff continued to support them and the person told us they had experienced similar behaviour from this member of staff. This meant the service had not listened to the person promoting a culture of openness or taking any learning from this person’s experience. This person said they did not feel safe when supported by this member of staff. We discussed this with the newly appointed manager who told us they would be reviewing the rota ensuring this person was not supported by this staff. They told us this would be fully investigated.

Whilst accidents and incidents were recorded individually and centrally to ensure management oversight, for some of the entries including complaints there were no actions recorded on the matrix. The spreadsheet had recorded ‘not set’ so it was not always clear what actions had been taken or whether there had been any learning.

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.

People confirmed they were supported to attend health care appointments when they needed to. People had access to health professionals including the community learning disability team, speech and language therapists and psychiatrists. People were supported to attend dental and optician appointments and were registered with a GP. Records were maintained of people’s appointments with the outcome, treatment plan and any follow up.

Hospital passports were in place to support people when they were admitted to hospital to ensure continuity of care. Staff confirmed they supported people in hospital acknowledging that the ward environment could trigger a number of emotions for some people. A person told us they had spent some time in the hospital and staff visited them daily to help them.

A professional confirmed they had a good working relationship with the service. They told us, “They maintain regular communication, promptly report any issues, and raise concerns when necessary. When asked to follow up with other professionals or arrange support for (person), they do so efficiently and in a timely manner. The management is hands on in terms of communicating”.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

Not everyone at the service felt safe. Two people raised concerns about the conduct of a member of staff who shouted at them. One person told us, “The majority of the staff are fine, but I do not always feel safe”. They told us about another incident where their call bell had been turned off and they were left for 2.5 hours without staff support. They told us, it was an agency staff member that was supporting them on this occasion. This information was shared with the newly appointed manager who confirmed an investigation was in progress and the agency staff would not return to the service. They had submitted a safeguarding referral to the local authority. The local authority confirmed receipt of the safeguarding concerns.

There was another incident where a person raised concerns about a member of staff’s conduct towards the end of 2024. Whilst this had been investigated, no notification of an allegation of abuse had been sent to the Care Quality Commission. This meant the Care Quality Commission had no oversight of the service and could not ensure appropriate action had been taken to safeguard people. However, the provider submitted evidence that a referral was made to the local authority safeguarding team.

Staff confirmed they had received online training to help them identify safeguarding concerns and the process for reporting allegations of abuse.

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

Whilst risks to people had been assessed and reviewed in relation to their support needs. Staff had often recorded the statement ‘no change’. Reviews of people’s risk assessments had not been completed following an incident, accident or a safeguarding concern. For example, one person had choked twice in the last 6 months, the person’s risk assessment had not been reviewed to ensure it was current and all actions were being taken to minimise further risk to the person. The manager confirmed the person had been seen by the speech and language team, but this had not been updated on the risk assessment, including the outcome. This was rectified with an updated risk assessment being forwarded to us in response to our feedback.

Another person had experienced a theft of money by a relative. There was no guidance for staff to follow to minimise further risks in respect of thefts of their monies. The risk assessment stated their cash box was in their flat. However, we saw person’s cash box was held in the office in an unlocked filing cabinet. Staff told us they did not know where the key was to ensure the person’s monies and medicines were held securely. An updated risk assessment was forwarded to us in response to our feedback.

One person’s risk assessment stated that the room to the staff sleep in area should be locked at all times as there was a risk the person may take staff belongings and paperwork. However, we found the door was propped open, which was not only a fire risk but also did not follow the risk assessment for this person.

One person’s records contained conflicting information about the texture of food provided, which meant it was not always clear that person was receiving food in line with their assessed needs.

Risks to people had not always been assessed effectively and this meant people were at risk of receiving unsafe care and treatment.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider assessed people’s flats for risks and took action to ensure people, staff and visitors remained safe. People had plans in place in the event they had to evacuate in an emergency.

There was a program of refurbishment being completed involving people. The housing officer visited the service to ensure the premises were safe and to support people with their tenancies and concerns about their accommodation. A person told us their flat was being refurbished, which they were looking forward to.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

People told us some staff did not always have the skills to support them and felt this maybe because they were agency staff or staff had not had the training to support them with their medicines and the use of the hoist. The manager was unable to locate records confirming all staff had been signed off as competent for medicines administration, supporting a person with a Percutaneous Endoscopic Gastrostomy (PEG) feed and moving and handling. A PEG feed refers tonutrition and fluids delivered via a Percutaneous Endoscopic Gastrostomy (PEG) tube. We saw staff medicine competence records that had recently been completed, but the section relating to competence of supporting people with a PEG had been left blank. A member of staff said they had been working in the service for three months and not been signed off to support a person with their PEG.

There was no formal and recorded induction for agency staff. This meant we could not be assured agency staff were being introduced to the service and the people they were supporting. The manager said usually it was regular and familiar agency staff that worked in the service, but no records were maintained to confirm agency staff had received an induction.

The manager provided assurances that training in supporting people with their PEG, Makaton and Trauma management was booked for September 2025. Notices were displayed confirming this on the office wall to ensure this was cascaded to all staff.

The provider’s audit had identified shortfalls in training with 73% compliance. The newly appointed manager was reviewing all staff training to ensure both face to face and online training was completed. This included medicine competences and observations of staff practice in moving and handling.

Staff confirmed they had received regular supervision and annual appraisals. A member of staff told us, “Supervisions are held every six weeks, which gives us the opportunity to openly share our thoughts, discuss training needs, and highlight areas where additional support may be required”.

Staff were recruited safely by the provider, and relevant checks were carried out before new staff started working at the service. This included criminal record and employment checks to confirm staff were suitable to care for people. The manager told us they were over recruiting by 10% to ensure continuity for people and reduce the use of agency staff working in the service.

People were supported by staff who had an induction that included shadowing more experienced staff. Staff were subject to a six-month probation period to ensure they were suitable to work for SeeAbility.

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.

Staff were responsible for supporting people to clean their individual flats. We observed that most areas of the service were clean and free from odour. However, the staff facilities were in need of a deep clean in the shower room. There was black mould around the shower plug and a walking aid being stored by the shower. The manager said staff do not use the showering facility. There was no toilet seat in the staff shower room and a number of buckets stored beside the toilet. This was fed back to the housing officer and the manager to address as this meant there was no suitable washing facilities for staff within the service should they wish to use them.

One person had an infection control risk assessment to keep them and staff safe from the risks of hepatitis B. However, not all risks had been mitigated such as ensuring staff were offered a vaccination. The manager was unaware if there was a policy in relation to the protection of staff. A member of staff who had worked at the service for several years confirmed they had never been advised to have the vaccination. The manager agreed they would discuss this with the provider’s health safety and team. The provider contacted us after the assessment to confirm this was being addressed including updating their policy to ensure staff had access to vaccinations.

Staff had completed training about infection prevention and control. Staff said they had enough personal protective equipment (PPE) such as gloves and aprons. Infection prevention and control policies were in place.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.Medicines were not always stored securely. We found one person’s medicines were kept in a filing cabinet in the office. This was not locked and secure. There were numerous packets of paracetamol that that had been opened in the bottom of the drawer. New storage had been purchased by day 3 of the assessment and medicines were now held securely.

Staff were not consistently recording room temperatures ensuring people’s medications were stored safely enabling them to take action if there were risks.

Not all staff were trained in the safe administration of medicines. Ten staff had not had their medicine competency completed. This meant on occasions staff had to leave the person they were supporting to ensure other people received their medicines. This did not lend to a person-centred approach.

Records were kept of medicines received and administered to people. Records of administration were kept ensuring that all medicines were accounted for electronically. This enabled the management team to monitor this remotely and take action where medications were missed. The management team maintained a log of medication errors. Stock control was thorough and enabled early detection of any discrepancies.

Protocols were in place for ‘as and when required’ medications and these were being reviewed by the GP. However, it was noted that one person had a protocol dated 2011. This medicine was no longer prescribed and there was no protocol for the medicines they had been prescribed for pain relief. This could lead to confusion. We found risk assessments were in place for people who were prescribed flammable creams. This ensured people were protected.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles.