South East Supported Living

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 good. At this assessment the rating has changed to:

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 the legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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 demonstrate a proactive and positive culture of safety based on openness and honesty. Whilst systems were in place to record accidents and incidents, these were not always effective in ensuring concerns were consistently explored, investigated, and used to drive learning. As a result, lessons were not always effectively identified or embedded to support improvements in practice.

Incident documentation often described what had happened but did not consistently demonstrate reflective practice or evaluation of contributing factors. For example, a medicines error involving missed doses identified “non-compliance” as a lesson learned but did not clearly set out how this learning would be shared or embedded into practice, nor address gaps in checking processes. In another incident, inconsistencies between the incident record and manager review limited assurance of a shared understanding, with no clear evidence of consistent staff response or identified learning.

There was limited evidence that learning translated into meaningful improvements or changes in practice. In addition, there was no formal system to analyse incidents over time to identify trends or patterns. This reduced opportunities to recognise potential risks, share learning, and drive service improvement.

Records showed that team meetings did not consistently revisit previous actions or clearly record timescales, responsible persons, or identify lessons learned. This was supported by staff feedback which indicated inconsistency in how learning was communicated and embedded across the staff team. This reduced accountability and limited the effectiveness of embedding learning and ensuring actions were consistently carried forward.

Staff described using electronic systems to record and escalate incidents and most said they felt able to raise concerns.

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.

The service demonstrated a coordinated approach to safe systems and transitions, with evidence of holistic pre-assessment processesthat considered both health needs and what matters to the person.

There was clear evidence of multi-disciplinary working, including recorded involvement with GPs and specialist teams including the Learning Disability team, ensuring continuity of care across services. Hospital passportswere in place, supporting safe and effective information sharing during transitions between settings.

The provider had systems and processes in place to safeguard people from abuse; however, these were not always effective.

The provider did not always ensure people were protected from avoidable harm. There were failures in the oversight and implementation of protective measures for 1 person, which meant known risks were not sufficiently controlled. For example, key safety measures were not effective or in place, including a non-functioning alarm system and unclear monitoring arrangements, leaving the person without a reliable means to summon help. This meant the person was exposed to an increased risk of harm, including unwitnessed incidents and delayed support. The provider took prompt action to safeguard the person.

Records did not consistently demonstrate that incidents or risks were fully considered within safeguarding processes. Documentation did not always clearly evidence whether events had been assessed against safeguarding thresholds. Where decisions had been made not to refer concerns to the local safeguarding authority, the rationale was not consistently recorded. For example, an incident involving a physical altercation between people using the service was recorded, however there was no clearly documented rationale for the decision not to raise a safeguarding concern.

This meant decision-making was not always clear, reducing transparency, accountability, and assurance that safeguarding procedures were applied consistently.

People told us they felt safe living in their homes, and relatives confirmed they felt their family members were safe. Staff had received safeguarding training and were able to describe how to recognise and report concerns.

The provider did not always work effectively with people to understand and manage risk.

Risk assessments and care plans did not consistently provide clear, detailed, or person-centred guidance, or involve people in managing their own risks. Risk assessments were not always updated when needs changed, and some lacked clear strategies to manage foreseeable risks. This meant staff did not always have the guidance needed to provide safe and consistent care. For example, 1 person’s plan for emotional distress did not include early warning signs, limiting staff ability to respond proactively. In another case, where a falls alert system was not working, risks were not promptly reassessed to ensure alternative controls were in place, although action was taken once this was raised.

Care planning records did not consistently reflect current needs and sometimes contained outdated or contradictory information, reducing clarity for staff. Examples included, 1 care plan instructed both weekly and monthly weight monitoring. Some health-related plans, such as for hernia support, lacked clear baseline information, expected symptoms, or escalation thresholds, limiting staff ability to identify and respond to deterioration. Inconsistent terminology, including mixed information about IDDSI (International Dysphagia Diet Standardisation Initiative), which is a framework that sets the standard for serving textured foods and thickened liquids to those with chewing and swallowing problems. There was also other outdated terminology, which further increased the risk of people receiving inconsistent care.

As a result, staff were not always supported to deliver proactive and consistent care, and people were not always fully involved in understanding or managing their risks, increasing the risk of harm.

The provider did not always detect and control potential risks in the care environment or ensure facilities supported the delivery of safe care. Although there were systems and processes in place to support a safe environment, we identified concerns relating to the external environment for two of the supported living services. This included missing fencing which allowed unrestricted access to a nearby road, and damaged fencing with exposed nails posing a hazard. These concerns had not been identified through existing monitoring systems. The provider acknowledged these concerns and confirmed action would be taken, including escalation to the landlord.

Equipment and people’s homes were generally well maintained, with regular servicing and safety checks carried out. People told us they could discuss maintenance issues with staff.

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.

There were safe and effective staffing arrangements in place,supported by robust recruitment processes and appropriate pre-employment checks to ensure staff suitability. Staff were trained for their rolesand had access to ongoing development.

Staff received regular supervision, training, and team meetings,which supported them in delivering care. Induction processes were in place and included training and shadowing.

Supervision was valued by staff and was consistent and useful across some services. However, in others, a small number of staff felt supervision had not always been effective or that their views were not always listened to; they reported this had started to improve following recent changes in service-level leadership.

The provider assessed and managed the risk of infection. People's home environments and equipment were visibly clean. Staff had completed infection prevention and control training and had access to relevant guidance. Personal protective equipment (PPE) and handwashing facilities were available in people’s homes

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

Medicines management systems were in place but they were not always effective. Whilst medicines were generally stored securely and records maintained, some documentation was incomplete or lacked sufficient detail. For example, PRN protocols did not always provide clear guidance for staff, particularly where variable doses were prescribed.

Processes were not consistently applied, for example independent checks of medicines administration were not always carried out, and there was no robust system to record medicines taken out of the service. We also found medicines keys were not always stored securely; however, prompt action was taken to address this.

Medicines self-assessments reflected similar issues. Whilst outcomes, such as a person’s ability to self-manage medicines, were recorded, there was limited detail about the information provided to people, the methods used to support their understanding, or their responses. This reduced assurance that people were fully supported to manage their medicines safely.

Medicines risks were assessed separately; however, there was limited evidence to demonstrate how control measures were implemented in practice. For example, a staff member reported using ice packs to manage high temperatures in medicine cabinets, however, there was no formal guidance, risk assessment, or clear instructions to support consistent and safe use. This meant no immediate risks were identified.