DDLTAC(UK) - LONDON

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 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 legal regulation in relation to safe care and treatment, staffing and fit and proper persons employed.

This service scored 53 (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 have processes in place to continually identify learning to improve the service and embed good practice.

There was an accident and incident policy in place and accidents and incidents were recorded. However, accident and incident forms did not include a section for lessons learned. This meant there was no record of the provider analysing what had happened and sharing learning with staff to reduce the risk of similar incidents happening. Therefore, we could not be assured the provider had an effective learning culture and had always learned lessons to improve the service.

The provider worked with the person and healthcare partners to establish and maintain continuity of care, including when the person moved between different services.

The provider had a ‘transfer document’ in place which included details about the person’s needs and support and shared it with other professionals when the person accessed other services. The provider also liaised directly and exchanged information with other services, including the person’s GP. The person was supported by the same staff on each social care visit. This ensured the person received continuity of care.

The provider did not always concentrate on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider’s safeguarding policy, systems and processes required improvement to ensure the person was always protected from avoidable harm. The provider’s designated safeguarding lead (DSL) was not trained to the safeguarding level set out in the provider’s safeguarding policy. The registered manager was also not trained to the safeguarding level set out in the provider’s safeguarding policy. The provider’s safeguarding policy needed to be updated regarding the details of the current DSL. The current named DSL told us they were not the DSL and had not been for the last 2 years. The registered manager told us the current named DSL was still the DSL. This meant the lines of responsibility and management of safeguarding referrals were not clear, which could lead to gaps, delays and omissions in safeguarding processes. Some care staff required further safeguarding training to be able to recognise all the signs of abuse and further whistleblowing training to know how to raise concerns outside of the service. The provider’s whistleblowing policy needed to be updated with the correct name and contact details for the local authority staff should contact to raise whistleblowing concerns.

However, we found no evidence the person had been harmed and there was no evidence of safeguarding incidents. The registered manager told us they would review the provider’s safeguarding policy and update it with the correct details of the DSL and the local authority. The person told us, “I feel safe with my carers. I trust my carers. Nothing bad has ever happened.”

The provider did not always sufficiently assess and record risks and instructions for staff about how to reduce risks.

The person had a risk assessment in place. However, it contained contradictory information and did not include all the necessary information regarding the risks. In addition, it had been completed by a member of staff who had not completed training in understanding risk.

The person’s risk assessment stated non-compliance with medicines was not an issue but also stated the person had a “…history of non-concordance [non-compliance] with treatment and medications in the past.”

The person’s needs assessment and medicines risk assessment stated they could display “aggressive” behaviour towards others when unwell, but this was not included in their risk assessment and there were no instructions for staff about how to support the person or manage the situation should this happen.

The person was assessed to need staff support with personal care and all activities of daily living. However, their risk assessment stated they were not at risk of self-neglect whilst also stating they had a history of disengagement from services, which meant the person was at some level of risk of self-neglect.

There was no specific risk assessment or care plan in place for the use of the person’s emollient cream (a skin moisturiser). Emollients soak into clothing, dressings, and bedding. They are highly flammable when dried onto fabrics, so they are a known fire risk. The fire risks of using emollients and how staff should reduce the risks should be set out in the person’s risk assessment and/or care plan.

The person’s care plan contained general information but did not include sufficiently specific information for staff regarding the person’s mental health needs, signs to be aware of and what action to take if the person’s mental health deteriorated.

The person’s care plan did not include sufficient specific information for staff regarding the person’s progressive neurological disease, signs to be aware of and how to support them should their condition deteriorate.

The person’s risk assessment and care plan did not include sufficiently detailed information for staff regarding the person’s risk of pressure sores and pressure injury care.

The person’s care plan did not include sufficiently detailed information about how staff should support the person to prevent isolation. It stated the person should be supported to maintain links with family but did not state who with or how it needed to be done.

The person’s care plan did not include specific or sufficiently detailed information regarding the management of the person’s finances.

These issues put the person at risk of potential harm.

This was a breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 12: Safe care and treatment

However, we found no evidence the person had been harmed.

The provider identified and reduced potential environmental risks.

They carried out a risk assessment of the person’s home, including fire safety and trip hazards, for example, which staff used to reduce health and safety risks to the person and themselves.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective training, supervision, support and development.

There were enough staff to meet the person’s needs. However, not all staff had completed appropriate training, including some compulsory training. Staff had not completed fire safety or first aid training, care staff had not completed dementia awareness training, and some care staff had not completed falls prevention training. The registered manager and the DSL had not completed safeguarding training to the level stipulated in the provider’s safeguarding policy. The provider’s training record did not include mental health training, and care staff had not completed mental health training, despite the person living with a diagnosed mental health need. No staff had completed learning disability and autism training. Since 2022 it has been a legal requirement for all care staff to complete learning disability and autism training, even if the service does not support people with a learning disability and/or autism.

Staff received regular supervision and the provider carried out spot checks. However, actions identified in supervision had not always been completed and spot checks were not carried out regularly. There was no policy, protocol or system in place for scheduling spot checks.

The provider’s supervision policy needed to be updated. It stated staff received supervision every 6 months. However, during our meeting with the registered manager they told us staff received supervision every 3 months, and supervision records confirmed this.

The provider carried out staff medicines administration competency checks. However, there was no evidence the provider had assessed staff competency in other areas of training and practice.

There was no evidence of staff meetings between February 2025 and November 2025 and between November 2025 and March 2026. Staff meetings did not have a clear format and agenda and there were no regular points/items for discussion in staff meetings. In addition, the staff meeting minutes contained minimal information and no clear learning or actions.

These issues put the person at risk of potential harm.

This was a breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 18: Staffing

There was a ‘Recruitment and Selection’ policy and procedures in place. However, the provider had not always followed safer recruitment practices, this included gaps in employees’ employment histories without explanation or a risk assessment, a reference from a company not listed in an employee’s application and not keeping all staff members’ DBS (Disclosure and Barring Service) checks up to date. A DBS check searches foran individual’s criminal record, including convictions, cautions, reprimands, and warnings held on the Police National Computer. The DBS checks for the registered manager and DSL were dated 2017. This meant the provider had not carried out DBS checks for the registered manager and the DSL for 9 years. Providers should carry out DBS checks every 3 years. During our assessment the provider carried out DBS checks for the registered manager and the DSL, which were completed in June 2026. In addition, the provider had not always carried out a DBS check for new staff when they presented with a DBS certificate from a previous employer. One member of staff who had presented with a DBS certificate from a previous employer had since changed address and the provider had not carried out a DBS check of their own.

The provider’s Recruitment and Selection policy did not include information regarding the policy and procedures for obtaining references for new staff from previous employers, it only gave instructions regarding what to do if the provider was required to provide another company with a reference.

These issues meant the provider could not always be assured new staff were allowed to work with vulnerable adults and had the competence, skills and experience necessary before employing them. This put the person at risk of potential harm.

This was a breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 19: Fit and proper persons employed.

The provider assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading.

There was an infection prevention and control (IPC) policy in place and staff had completed IPC training and used PPE appropriately. The provider ensured staff had a sufficient supply of PPE. The person said, “The staff wear gloves and aprons and face masks.”

The provider did not always make sure that all aspects of medicines management were safe. Some medicines information required improvement.

The person’s care records included some information about their medicines. However, their care plan did not include a list of their medicines, the reasons for taking each medicine, the signs of an adverse reaction and instructions for what staff should do in the event of an adverse reaction.

However, Medicines Administration Records (MAR) charts were completed correctly, medicines audits were carried out monthly, and follow-up actions identified in the audits were implemented. Staff knew the person and their needs well, and the person had received their medicines as prescribed. The person told us, “There has never been a problem with my medicines.”