Catherine Tam 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

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 outstanding. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 94 (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 had a strong, embedded learning culture where people were kept safe through openness, honesty and continuous improvement. There was a clear expectation that safety concerns would be raised, listened to and acted upon, and staff demonstrated confidence in reporting incidents and sharing learning.

Systems and processes to support learning were well established and consistently applied and embedded. Incidents and accidents were recorded in detail, including what had happened and the immediate actions taken. These were subject to regular analysis to identify trends, themes and potential risks. This enabled the provider to take a proactive approach to reducing recurrence and improving safety across the service, resulting in a measurable reduction in repeat incidents and increased consistency in the way risks were managed for people.

Learning was shared effectively. The provider completed a ‘significant event analysis’ when incidents happened. These reviews explored what happened, why it happened, what worked well and what could be improved. These analyses looked at what needed to be escalated, and what could be done to manage and reduce the risk. The provider utilised “huddle” discussions following incidents, promoting a culture of openness and collective learning. Learning outcomes and actions were formally documented and shared with all staff, ensuring transparency and consistency in practice. The registered manager maintained oversight of this process and ensured that all actions were implemented, including reviewing risk assessments, updating support plans and communicating changes clearly. This meant people received more responsive and individualised care, with support approaches adapted quickly to reflect learning and better meet their needs.

The provider carried audits to reflect on people’s support. One of these audits looked at how people expressed their emotions. This analysed any themes in emotional distress. Staff learning briefings reflecting the findings and implemented change or training needs in order to support people to live without uncertainty or fear. These learning briefing also provided feedback from audits of daily logs and how they linked to care plans. They detailed what was missing and detail what good record keeping should look like. This benefitted people, as detailed information was then readily available for healthcare professionals when needed. This was reflected in the positive feedback received from external healthcare professionals.

People benefited from a positive approach to risk-taking. The provider ensured that risk was managed in a balanced and person-centred way, enabling people to achieve greater independence. Through robust assessment, planning and gradual support, people were supported to access the community independently. This demonstrated a culture where learning from risk was used to improve outcomes, rather than restrict opportunities. As a result, people achieved significant progress, including increased independence in situations that had previously been considered high risk, alongside improved confidence and wellbeing.

Staff were supported to learn and improve. They told us they felt valued and encouraged to develop their skills. Learning was encouraged and supported through regular supervision, team meetings, audits and partnership working. Staff understood their responsibilities in relation to safety and continuous improvement, which led to more skilled and confident practice when supporting people.

Lessons from incidents and feedback were embedded into everyday practice, leading to safer care, greater consistency and improved quality. The provider demonstrated that learning resulted in meaningful and sustained changes, with clear evidence of improved independence, safety and wellbeing for people using the service.

The provider consistently worked in partnership with people, their families, carers, and healthcare professionals to design, establish, and maintain safe systems of care where safety was effectively managed and closely monitored. They always ensured continuity of care, including when individuals transitioned between different services.

Staff gathered comprehensive information in advance from people, their families, carers, and professional partners. This enabled them to fully understand people’s needs, risks, communication styles, sensory preferences, and daily routines prior to every stay. This detailed information informed robust and well-structured transition plans. Staff also reviewed these plans thoroughly and met people ahead of their move into the service to support a smooth transition.

Transition plans were highly person-centred and detailed, reflecting a clear understanding that people were more than their support needs, and that transitions were emotional experiences rather than simply logistical processes. Plans included clear timescales, with preparation tasks broken down step by step, and clearly identified who would provide support on the day of the move. Following admission, the provider maintained regular reviews, collaborative planning, and consistently delivered person-centred support.

Catherine Tam Agency had successfully supported several people to move from long-term residential care into more independent living arrangements. They demonstrated strong awareness of the risks associated with such transitions and ensured that each move was carefully planned, managed, and supported.

Families consistently shared positive feedback, reporting that they felt reassured by how staff managed transitions. One family member commented, “[Person] was given a selection of staff to see who they got on with best. This was then refined to a smaller, consistent team to promote familiarity and continuity of care.”

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus 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 always shared concerns quickly and appropriately.

The provided had a dedicated approach to safeguard people they support. This approach was coproduced with staff and people using the service. They recognised people as experts in their care and empowered them to provide training sessions around safeguarding with staff. They discussed their personal experiences of safeguarding and reflected the impact excellent care and support had had on their outcomes.

Furthermore, people have been supported to be involved in interviews of potential new staff. Their views and involvement in staff recruited was at the centre of the providers commitment to make sure people felt safe and supported.

Staff exhibited a very clear understanding of their safeguarding roles and responsibilities. Staff actively engaged people in discussions about safeguarding, raising awareness and empowering them to recognise risks. Training was effective, equipping staff with the knowledge and confidence to identify signs of abuse or neglect and to take timely, appropriate action.

Safeguarding practice within the service was highly personalised. The provider embedded the principles of Making Safeguarding Personal, ensuring that people’s individual views, experiences and preferences were central to all decision-making processes. Staff worked closely with people to understand what feeling safe meant to them and tailored support accordingly.

For example, staff supported people to build confidence and develop strategies to safely access the community. Where appropriate, and following thorough risk assessment and agreed safety planning, individuals were enabled to access the community independently. This approach promoted independence, dignity and positive risk-taking, while maintaining a strong safeguarding framework.

The provider demonstrated a clear commitment to involving people in safeguarding processes. They recognised that safeguarding began with the person and they worked with people to identify what made them feel unsafe, and how they could be supported to feel safe. They stated, “It starts with making safeguarding personal, it’s all about making sure people are involved. They have the right to say whether they want it escalated or not and are involved at every point. If they wish, their relatives can also be included.” This approach ensured that people remained at the centre of safeguarding decisions.

The provider maintained a comprehensive safeguarding log, recording all concerns, including those not formally investigated by external safeguarding teams. This proactive approach ensured oversight of emerging risks and demonstrated a strong commitment to continuous monitoring and learning.

The provider worked exceptionally well with people to understand and manage risks holistically. Care was consistently safe, supportive and enabled people to do the things that mattered most to them, promoting independence and meaningful lives.

Care plans and risk assessments were highly personalised, detailed and comprehensive. They supported positive risk-taking and included clear guidance for staff, such as personalised positive behaviour support (PBS) plans. These plans identified people’s individual needs, preferences, early signs of distress and specific strategies to provide reassurance, ensuring staff delivered consistent, respectful and effective support.

Risk management extended beyond the service into the community. People were actively supported to access meaningful opportunities, including local activities, places of worship and visits to significant locations. Innovative and person-centred approaches enabled people to achieve important goals, such as travelling abroad and reconnecting with loved ones. These were not one-off events but sustained opportunities that enriched people’s lives. One person described a long-awaited visit to family overseas as bringing them “peace,” reflecting the profound impact of the support provided.

Overall, the service demonstrated an outstanding commitment to enabling people to safely manage risks while living fulfilled and meaningful lives.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

CQC does not regulate the living environment within supported living services as the premises are usually owned by landlords and housing providers, who are not registered with CQC. However, we found each person’s accommodation had cleaning schedules, with the person being supported to maintain their own accommodation to a good standard.

People’s properties were highly personalised and decorated to their own choosing. One person told us, “I got to choose how I wanted it. Not only that, I got to paint and chose the furniture myself.”

Relatives also gave positive feedback on people’s personal spaces. One relative told us, “It is a beautiful bungalow and lovely kitchen. He is encouraged to do the cleaning and if he doesn’t do it staff do.”

Fire safety was well managed throughout the service. Each person had a detailed Personal Emergency Evacuation Plan (PEEP) outlining the support they would require in an emergency. Testing of fire alarms were carried out regularly to ensure they were in good working order.

Changes were made to people’s living environments where there were any concerns about a person’s safety, or their needs changed. For example, one person had a new wet room installed prior to them moving in as this was identified during the transition process. Their relative told us this was done without delay.

Another person was found to be struggling with mobility. The provider applied for a grant to build a ramp so they were not compromised by the steps. This provided the person with more freedom and independence.

Additionally, a person had expressed a wish to have their own pets. The provider worked with them to identify any adaptations needed, risk assessed and support the person with understanding the responsibility of caring for a pet. The provider then supported the person to adopt a rescue cat. The person told us how this had given him responsibility and something to love and be loved by.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staffing rotas were in place that evidenced how many staff were available to care for people.

People had established staffing groups, who knew the people they supported well. One relative told us, “[Person] has the same regular staff with [them]. Weekends and nights are the same.”

People told us they had trust in the staff that supported them and that staff knew their individual needs and requirements.

Staff were recruited safely, with appropriate pre-employment checks carried out before staff started working with the service which included Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had opportunities to learn, and any poor performance was managed appropriately.

Staff told us they received detailed training which was specific to the people they supported. Training included internal and external training, as well as training being offered by people they support and their family members. This offered highly personalised guidance which equipped staff with the skills and knowledge to meet people’s individual care and support needs. Staff had received training around supporting people with a learning disability and autism.

The provider has supported staff through career development into leadership roles, apprentices and nursing associate programmes. In addition to this, the provider invested in counselling for staff, offered mental health first aider training, wellness action plans and reflective practice sessions.

The service invested in mandatory training which revolves around how they supported people to live well, how to have quality of life and to recognise the person for they were. This training explored staff personal journeys and what made them want to work in this area of employment.

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.

Staff had received training in infection prevention and control, to support their understanding of best practice. Cleaning schedules were in place in each person's property. Staff had the responsibility of cleaning within the supported living properties and where possible, people who used the service were encouraged to help if they were able. We observed people’s living environments were clean and tidy at the properties we visited.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People had medicines care plans in place which provided detailed information and guidance to staff on people’s medical needs.

People told us medicines were managed safely by staff, and staff demonstrated clear understanding of people’s prescribed medicines.

The service had an understanding of Stopping Over Medication of People with a learning disability and autistic people (STOMP). One person at the service told us how staff had supported them to reduce over reliance on medicines, by working with them and relevant health professionals.