SeeAbility Buckinghamshire 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 a legal regulation in relation to people’s safe care and treatment and the way people’s medicines were managed.

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 manager had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, improvements were required to ensure lessons were learnt to continually identify and embed good practice. For instance, we found the provider had not ensured feedback from us at another location had been fully embedded at this service. We found similar concerns about risk assessment and daily records at both assessments.

We found incident and accident reports were completed, however, there were delays in these always being actioned. At the time of the assessment, 34 incidents were still showing as outstanding and needed to be signed off by the registered manager as reviewed and action taken to prevent a reoccurrence. We noted an incident had occurred and this had been discussed at a team meeting on 1 April 2025, however, we could not see the incident form at the service. The registered manager advised us this had been archived. This could have impacted on the service’s ability to look at trends and themes, as it was not readily available. Once we did see the incident form, we learnt the incident had occurred in December 2024. This meant there was a delay in this being discussed at team meetings to ensure lessons were learnt.

Feedback on how well the service learnt from complaints and concerns was mixed. A relative told us there had been a high staff turnover, which had impacted the knowledge held by staff about their family member stating, “When they had an agency the service went downhill... very different to when [person] moved in.”We discussed the use of agency staff with the registered manager who confirmed the service had used agency staff on a “very small number of occasions”. They also told us when used they booked the same agency staff to ensure consistency. Other people and relatives commented,“My relative has been there since 2017 not had many issues but have had some issues” and “This is one of the better services.”

We found examples where some lessons had been learnt across the organisation and action taken to prevent a reoccurrence. For instance, regarding financial abuse and prevention of scalding with the use of hot water bottles.

Staff told us they had the confidence to complete accident and incidents forms, and systems were available for senior staff to audit accidents and incidents.

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 told us they knew which staff would be supporting them and had some continuity of support. We found the registered manager and staff maintained good communication with external parties to ensure people had timely referrals made which had a positive impact on them.

Systems were in place to ensure information was available for staff to send with people when they were admitted to hospital. One person had recently been supported to go to a hospital appointment and they were keen to tell us the outcome and how staff supported them.

People were supported by staff who 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 and had worked with the local authority safeguarding team to investigate concerns when raised.

People told us they felt safe in the presence of care staff, and they were confident in the care being delivered. Comments included, “Yes, I feel safe” and “Yes, I feel safe… I can get around the best I can.”

Staff had received training on how to recognise signs of abuse and were able to tell us about how to support people to keep safe and protect them from abuse or harm. One member of staff told us “I make sure training is up to date…being aware of what abuse is and what to look for”. Another member of staff told us they would not hesitate to raise a concern with a “colleague” or “management”.

The provider supported staff to understand their role in safeguarding people from abuse. The nominated individual told us “Within the SeeAbility Buckinghamshire Support Service Portal, we have developed the Safeguarding Zone, an area that links to external safeguarding resources and sets out all of our own safeguarding-related tools and processes.”This portal was available to all staff across all the provider’s locations and all staff.

People were not routinely protected from risks posed to them. We found risk assessments were not always updated in a timely manner to ensure staff had up to date information on how to prevent harm to people, and risk assessments were not always in place.

People had multiple risk assessments in place, but these did not always show people had been involved or corresponded to people's needs. We noted a person who was at a risk of choking, had been assessed to only being able to eat bite-sized pieces of food with 1:1 support. A choking risk assessment was in place; however, it did not contain this information, nor did it contain any updated guidance. We observed the person eating food that was not bite sized and this could have caused the person to choke and become unwell. This meant that people were not always kept safe and fully supported to meet their needs.

However, the provider encouraged positive risk taking and people were encouraged to undertake positive risk taking. The nominated individual gave us examples of how the service supported people to manage risks and risk management.

Where the service had recorded a person was diabetic, the service had reviewed their care needs and we found information about additional checks carried out to maintain their health. For instance, eye screening and foot care.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We observed the service was not equipped or suitably prepared in the event of a fire. A fire grab bag did not contain industry recognised items, such as communication aids and enough emergency blankets for all people living in the supported living accommodation. Theprovider took swift action to ensure this was rectified, before our second site visit. In addition,each person did have a personal emergency evacuation plan in place to advise staff on how to support them in the event of a fire.

We found people were exposed to hazards in communal areas of the supported living accommodation. This placed them at a greater risk of harm. For instance, people had free access to an electrical cupboard which housed high voltage plugs. A room used for staff to sleep in at night time was unlocked and people had access to it. We found a window restrictor was open, which meant people were exposed to risk of falling from height.

On the first day of our inspection, for a person whose bathroom was being cleaned by staff, water had escaped into the person’s bedroom. There was no risk assessment in place. This person mobilised in an electric wheelchair and in addition they had many electrical items in their room. This placed the person and staff at risk of harm. We discussed this with the registered manager and provider to ensure this was not repeated in the future.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, we received feedback from one relative about delays in care being provided to their family member. We have provided this feedback to the service.

People were supported by staff who had been recruited with robust recruitment processes. There were staff available to support people when they needed assistance. Rotas reflected people’s individual daily support and staff were allocated to meet those needs.

We observed people being supported at various times throughout the day and saw their needs were met in a timely manner. One member of staff told us “When I arrive for my shift, I always know what floor I will be on and who I'll be supporting, with the people we support it is a team effort and near all of us get along and get along well with the people living at the service.”

Staff recruitment files contained full and robust checks as required, including a Disclosure and Barring Service check. This checks for criminal convictions and inclusion on lists of people who would be unsuitable to work with people at risk. However, one of the requirements under the legal regulations was not present. The registered manager confirmed no recent photograph of each member of staff was available.

Staff told us they felt well supported in their roles and received appropriate training, supervision, and guidance to carry out their duties effectively. Staff told us they had opportunities for career development. This was supported by what the nominated individual told us “Career development is a key priority for our charity, 48% of all staff vacancies are filled internally.”

Staff were keen to tell us about recent training they had received about brain injury. Systems were in place for the registered manager and provider to monitor staff compliance with training. We noted where bespoke training was required, this was arranged.

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.

We received mixed feedback from people and their relatives about the cleanliness of the environment, both in each person’s room and in communal areas. We observed risks were posed in communal toilets, dispensers for handwashing and hand towels were empty, a kitchen roll was left on top of a radiator and hand sanitiser was left on top of a toilet cistern.

One relative told us they felt the environment could be better cleaned. We noted another relative had made a complaint to the provider in June 2025 about their relative’s room which had not been cleaned by staff as expected. One person told us “One of the [staff] members do not clean and they should.”

However, people told us staff followed appropriate infection control procedures, helping them to feel safe and protected during support. People we spoke with confirmed that staff consistently wore personal protective equipment (PPE) such as gloves. We noted there was enough supply of PPE which was readily available to staff.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found medicines were not routinely and consistently stored in line with the manufacturer’s guidelines. In one person’s medicine cabinet in their room, we identified 4 medicines were no longer safe for use as the medicines had passed their expiry dates. This had the potential to cause harm to people if administered. This had not been identified by the registered manager or the provider. One of the medicines had an expiry date of October 2023.

In a separate medicine stock cabinet in the provider’s office, we found 2 medicines which were no longer safe for use as the medicines had passed their expiry dates. These issues were rectified upon verbal feedback to the provider with a new system put in place to ensure out of date medicines were sent for disposal.

We found other medicines which were not safe to use as they had been opened for more than 28 days. No opening dates had been recorded which meant staff could not be assured they were still safe to use.

Systems were in place to monitor and audit medicine management, however, they did not identify the issues we found.

People were supported by staff who had received training in the safe administration of medicines. People and their relatives told us they had no concerns with how people received their medicines.