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 remained outstanding.

This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

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, which included 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, which promoted a culture of openness and collective learning. Learning outcomes and actions were formally documented and shared with all staff, which ensured transparency and consistency in practice. The registered manager had maintained oversight of this process and ensured that all actions were implemented, which included reviews of risk assessments, updates of 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 had learning briefings that reflected the findings and implemented change or training needs in order to support people to live without uncertainty or fear. These learning briefings also provided feedback from audits of daily logs and how they linked to care plans. They detailed what was missing and detailed 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, which enabled 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, which included 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, which led 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, which included when individuals transitioned between different services.

Staff had 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 care starting. 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, that reflected 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. 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, and reported that they felt reassured by how staff managed transitions. One family member commented, “[Person] had been at [the providers] nursing home. They supported me in trying to get him home and he has now been home for 2 years. I insisted that [Catherine Tam Agency] provided care at home. They already knew him and had developed learning. It was what I wanted.”

Thank you for your response. Following review of the information, the report and score has been amended to reflect the evidence.

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

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, which ensured staff delivered consistent, respectful and effective support.

Staff had understood that risk management was not about restricting people but enable them to try new things safely, learn skills and make informed choices. For example, a person the provider supported experiences a stroke and it was considered too high risk for them to return home by professionals involved. Due to communication difficulties,

Risk management extended beyond the service into the community. People were actively supported to access meaningful opportunities, this included local activities, and places which held meaning to them, and gradually built on their independence. Innovative and person-centred approaches enabled people to achieve important goals. These were not one-off events but sustained opportunities that enriched people’s lives. Using pictorial prompts, accessible communication and staff who knew him well, the provider worked in genuine co-production with the person to ensure their wishes, preferences and goals remained at the heart of the planning process. With family and professionals, they devised a risk management plan, focusing on what mattered to the person. Now able to access the local community independently, this persons journey demonstrated that positive risk-taking is not about avoiding risk, but about enabling people to live the life they choose, with the right support to achieve meaningful, sustainable independence.

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 registered manager informed us that risk assessments of people’s homes were conducted prior to the commencement of the care package. This process was undertaken to ensure that the environment was safe for staff members, but also to ensure people were in safe home environments.

Environmental assessments were in place, and staff demonstrated familiarity with people’s homes and safety arrangements. The provider had worked closely with people, their families and professionals such as occupational therapists to thoroughly assess people’s home environments. They had supported one service user who used a wheelchair to create lower work surfaced to enable them to prepare meals, promoting their independent living skills.

Another service user experiences intense feelings of abandonment when their family were not around. The provider worked together to create collection of family photographs, which are displayed throughout their home, alongside portable photographs and a personalised family album that could be used wherever they chose. These were used as part of daily conversations and reminiscence, enabling the person to talk about the people who are most important them. This personalised approach strengthened the relationships between the person and their support staff. By adapting their home environment, they had created an environment that promoted both emotional security and physical safety, enabling the person to remain living happily in their own home.
 

Relatives also gave positive feedback on people’s personal spaces and the support carers provide to ensure they are well-maintained and safe.

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 had effective infection prevention and control (IPC) measures in place that promoted people’s safety and wellbeing. Staff followed infection control processes, and the safe use of personal protective equipment (PPE) demonstrated a strong understanding of how to reduce infection risks.

Staff had received training in infection prevention and control, to support their understanding of best practice.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, which included 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 understood the guidance 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.