Beyond Limits (Plymouth)

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 Good. At this assessment the rating has changed to 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 88 (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 an exceptionally strong and proactive learning culture that was embedded throughout the service and had a significant positive impact on people’s lives. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Safety was prioritised through openness and complete honesty, creating an environment where staff felt confident to raise concerns, reflect on practice and identify opportunities for improvement. Lessons were always learnt to continually identify and embed good practice. This approach enabled people to live safely in their communities while pursuing their goals, maintaining their independence and achieving outcomes that mattered to them, without being subject to unnecessary restrictions.

The registered manager explained that a strong and transparent learning culture was fundamental to the service's ability to support people in the community who required a high level of skilled support to keep themselves and others safe. During staff interviews, they were open and transparent about the potential risks involved, including the possibility of staff being injured or the person being supported engaging in self-harming behaviours. They explained that it had taken commissioners some time to understand their approach, particularly their willingness to take calculated risks to enable positive outcomes, and to gain a full understanding of how the service operates and delivers support. An external professional told us, “They are a resilient provider.”

The registered manager told us, “We try not to operate a blame culture as the fear of blame may hide incidents or near misses. It will build trust to openly speak up and supports better outcomes. Therefore, we want to use neutral language such as staff member X was involved in the incident, we want facts, actions and learning points.” Structured debriefs were embedded into practice to support staff, exploring what happened and identifying any opportunities for improvement. Robust systems and protocols were in place for the recording, reviewing and oversight of accidents and incidents. These included safeguarding registers and monthly reporting to senior leaders to identify trends, patterns and emerging risks. This meant the service could respond quickly to concerns, reduce the likelihood of similar incidents occurring and continually improve the support people received.

The provider had used learning from incidents to further develop and strengthen the safety of the service. The registered manager explained how risk management processes had evolved over time in response to lessons learned from incidents, changes in people's needs and circumstances, and updates to legislation. They told us, “Over the years, our safety assessments have continued to evolve through learning opportunities identified following incidents. This has enabled us to strengthen preventative measures, improve clarity, and ensure assessments remain relevant as needs, circumstances and legislation change.” The recent introduction of a new safety assessment format had provided, “a better overall picture of the person and what they wish to achieve, gives staff a clearer understanding of risks and how these are managed, and improves risk identification through clearly defined sections and responsibilities. The assessment is more person-centred and supports better communication.”

The provider consistently worked with people and healthcare partners to design, establish and maintain safe systems of care. This meant safety was proactively well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service demonstrated exceptional effectiveness in working collaboratively with people and partner organisations to promote safe care and transitions. They supported people with complex needs to move from long stay hospitals and institutional settings into independent living in the community. A structured 12-week ‘start-up’ period was used to build trust and develop a thorough understanding of each individual’s needs, preferences, and aspirations. This could be extended if required to ensure the transition remained led by the person being supported. Information gathered during this process informed the development of bespoke support packages tailored to each person's strengths, goals and support needs. People were actively involved in decisions about their future and were supported to choose the staff who would support them, alongside identifying and establishing suitable homes within their chosen community.

To promote continuity and safety, prospective staff teams had opportunities to work alongside people in their existing institutional settings before the move. This was done in a ‘staggered’ way so as not to overwhelm the person. Staff could also undertake ‘community mapping exercises’ to familiarise themselves with local facilities, services and opportunities available in the area where the person would be living. This enabled staff to develop a detailed understanding of how best to support individuals to establish meaningful and independent lives within their local communities.

The effectiveness of the processes used to support people’s transition from more restrictive settings into the community was evident in feedback received during the assessment. For example, one relative told us their family member had never previously received care that fully met their needs. Since moving from hospital and receiving support from the service, the person had “come a long way”, was making their own choices and had “found their voice”. The relative said risks were well managed and that the service had put the right support in place to enable a safe and successful transition while promoting the person's independence and wellbeing.

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.

The service protected people from abuse and poor treatment. There were clear safeguarding systems, with concerns reported to a designated lead and monitored through a safeguarding register to identify risks and trends.

All staff, regardless of role, received safeguarding training at induction and ongoing learning, including understanding whistleblowing and recognising poor practice. Safeguarding concerns were appropriately reported and investigated. For example, incidents such as medication errors and injuries were escalated to safeguarding and reviewed fully, with actions taken to reduce future risks.

People told us they felt safe. One person said staff were “really kind and help me,” and another told us they were confident concerns would be addressed. An open culture and a new ‘whistleblowing hotline’ encouraged staff to speak up.

The provider commissioned external audits of its safeguarding processes and systems to provide independent assurance of their effectiveness and to help maintain the safety and quality of the service. Findings from these audits were used to identify areas for improvement, strengthen safeguarding practices, and ensure systems remained robust, responsive and aligned with current best practice. This demonstrated the provider's commitment to continuous improvement and to protecting people from the risk of harm and abuse.

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.

The service was exceptional at involving people and those important to them in managing risks while promoting independence. A strong, person-centred ethos was embedded in practice, demonstrated by the service’s deliberate reframing of ‘Risk Assessments’ as ‘Safety Assessments.’ The registered manager explained, “This wording supports more positive, enabling language by focusing on safety rather than danger or restriction. We believe it encourages positive risk-taking and helps reduce a risk-averse mindset.” Positive risk-taking was actively encouraged and supported through robust assessment, planning and ongoing review. Where risks were higher the service worked proactively with external partner agencies to manage and mitigate these risks effectively. This approach ensured people were empowered to make choices and maintain independence while risks were carefully managed.

One person wanted to pursue an active social life, including going to pubs and clubs and meeting new people. The service developed a detailed, person-centred safety assessment which recognised and addressed potential risks associated with this activity, including the possibility of seizures triggered by flashing or strobe lighting, the interaction between alcohol and prescribed medication, and the risk of exploitation. These risks were not used to restrict the person’s choices. Instead, clear and proportionate measures were co-produced with the person and their family to enable them to participate safely. This meant the person could continue to enjoy meaningful social experiences while minimising potential harm.

This approach demonstrated the service’s commitment to positive risk-taking, ensuring people were empowered to live full and inclusive lives, with carefully planned support that promoted both safety and 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.

People were supported in their own homes, with expectations for cleanliness and safety clearly agreed through care plans and discussed in a sensitive and respectful way. This ensured that safety was maintained without undermining people’s dignity, choice, or sense of ownership of their home.

Robust policies and processes underpinned this approach, ensuring environments were kept safe while recognising that people’s homes remained their personal spaces. These policies promoted meaningful involvement, encouraging people to participate in decisions about the safety of their home wherever practicable. This supported independence and enabled people to retain control over their living environment.

A comprehensive programme of regular safety checks was in place, covering equipment such as wheelchairs and epilepsy-related devices, as well as vehicles and COSHH-related risks. In addition, an annual home safety survey was completed for each property to ensure standards were sustained and any issues were promptly identified and addressed.

The provider worked in partnership with Devon and Somerset Fire and Rescue Service. All people supported had received a Home Safety visit, further strengthening fire safety arrangements. Personal emergency evacuation plans were in place for each property, and regular fire drills, undertaken at least twice yearly, ensured both people and staff were well prepared and confident to respond effectively in the event of an emergency.

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. People and relatives consistently praised staff, describing them as “exceptional”, “well trained” and “brilliant”.

The staff recruitment process was exceptionally person centred and driven by the people being supported. Individuals (and families where appropriate) identified the qualities they wanted in staff, which shaped tailored job adverts and selection. For example, one person expressed a need for a consistent staff team to help them feel safe, highlighting attributes such as “confident risk takers” and being “playful and able to make up stories.”

People were actively involved in choosing their staff, including interviewing candidates and making final decisions about their recruitment. Staff described how they had been interviewed by the person they support using “thumbs up/thumbs down” questions. Another person had chosen family members to join their support team. This approach ensured strong matches between staff and individuals, helping people feel safe, understood, and empowered.

Staff said they were well supported through supervision and ongoing development opportunities. They received appropriate training for their role, including mandatory training on learning disabilities and autism, and bespoke programmes tailored to meet people’s complex needs such as epilepsy management and behaviour support. A relative told us their family member supported the induction of new staff within their team and was paid for this, demonstrating a person-centred and inclusive approach.

Staff told us their training gave them the confidence to support people to engage in activities of their choice within the community. They demonstrated a clear understanding of how to maintain the safety of individuals and others, for example by recognising potential triggers and applying de-escalation techniques effectively. This enabled staff to support people to participate in activities they enjoyed, in a safe, positive and meaningful way.

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 service maintained effective infection prevention and control (IPC) practices. Each person being supported had a bespoke individual contingency plan outlining the support needed in the event of an infection outbreak or other emergency. Staff completed mandatory training in infection control, including hand hygiene, Personal Protective Equipment (PPE) and recognising infections.

Care plans set out individual expectations for cleanliness, balancing infection control with people’s rights and preferences. Staff promoted good hygiene practices daily, including safe waste disposal and laundry processes.

There were adequate supplies of PPE, and staff confirmed equipment was readily available when needed. The service kept up to date with national guidance and encouraged vaccinations for staff and people.

Feedback indicated IPC practices were embedded in daily care, although these were adapted flexibly to suit people’s home environments.

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

The service managed medicines safely and effectively and demonstrated a clear commitment to the STOMP (Stopping Over Medication of People with a Learning Disability, Autism or Both) principles. Robust medication management systems were in place, including clear protocols for the use of PRN (when required) medicines, with appropriate authorisation, recording and monitoring arrangements. Staff received specialist training to support people without relying on medication and were equipped with alternative strategies to prevent and manage distress. This included person-centred CALMS (Crisis Aggression Limitation Management) training, and PBS (Positive Behaviour Support) training, tailored to the specific needs of each individual and delivered directly to the staff team supporting them. Staff had a detailed understanding of people's triggers, behaviours and support needs, enabling them to use proactive de-escalation techniques and personalised interventions. As a result, PRN medication was used only as a last resort when other strategies had been exhausted.

Staff received training and competency checks in medicines management, with regular audits and monitoring systems in place. The service worked with health professionals to review medicines and reduce unnecessary use, including annual medication reviews. People were supported to be involved in managing their medicines where appropriate. For example, some people administered their own medicines with staff oversight and regular safety checks in place. Clear policies and procedures guided this practice, promoting people’s independence and right to make choices, while ensuring any associated risks were appropriately managed.

When errors occurred, these were investigated thoroughly, reported to safeguarding and used to improve systems and training.