One Step South Domiciliary Care 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 – 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 changed to “Good”. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were robust processes in place to analyse any incidents or accidents to understand any contributory factors and put in place additional measures to ensure people’s safety and prevent these reoccurring. For example, one person had frequently become extremely distressed which had exposed themselves and staff to a risk of harm. Through involvement from their internal Positive Behaviour Support team and analysing these incidents, the provider had put in place communication strategies to reassure this person which had reduced incidents of distress from 8 in the first quarter of the 2025 to only 1 incident in the second and third quarter. We saw other similar examples of learning being taken which had notably improved people’s quality of life and mental wellbeing.

Staff told us that they were continually learning as a team, and explained that after incidents there would be a debrief which gave them a safe space to reflect and take learning to improve the care being provided. Any lessons learned were shared with staff through meetings or in handovers between shifts. One staff member told us “We have debriefs where staff can share any concerns, and management will review what has happened to look for any learning”.

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. There were clear pathways in place to ensure people received safe and consistent care when moving between services. People had comprehensive health action plans which were regularly reviewed and set out all other services involved in people’s care. These included timescales showing when people required a regular review such as with their dentist, specialist mental health or learning disability teams or specialist community teams supporting conditions such as diabetes or epilepsy. The plans clearly showed any adjustments people might require to access these services safely, the advice or outcome of their most recent reviews and how the service would support this in being implemented and reviewed on a day to day basis.

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. We found staff and the provider were proactive in responding if there were any concerns that people were at risk of abuse or neglect, including making prompt referrals to the local authority to allow action to be taken if needed to protect people. Staff had a good understanding of what signs they would look for that may indicate a person was being abused or suffering neglect, and could confidently explain how they would report these concerns. One staff member told us “Abuse could be sexual, financial, physical, or self neglect. I know what to look out for and would inform my manager. I could also contact our locality manager if I felt action was not being taken to protect someone. The contacts for our local authority safeguarding team are available if I need.”

Where appropriate, the provider sought relevant authorisation under the Deprivation of Liberty Safeguards (DoLS) process if appropriate to safeguard people from the risk of harm to themselves. These were regularly reviewed and people’s representatives were involved in the process.

Staff worked closely with people to ensure they were at the centre of any safeguarding enquiries, and were continually updated and involved in the process so their wishes and needs were at the heart of any investigations. This included using formats such as easy read to ensure information was in a format people could understand. One person told us “My team worked with me to understand what safeguarding means. Now I understand what is going on and feel involved in the process. Partner organisations fed back that the service worked constructively and openly with them to ensure any appropriate actions were taken to safeguarding people from harm. A professional working alongside the service observed they worked to ensure any investigations which had the potential be distressing were handled sensitively and reflected the communication needs of individual people, for instance by having daily focused conversations to provide emotional support.

The provider did not always work well with people to understand and manage risks. Although staff were knowledgeable about the risks to people and how to respond to protect them from harm, we identified some improvements were needed to ensure the guidance was always sufficiently detailed. People being supported had care plans in place which detailed how staff would support people in managing any risks. These were reviewed regularly including alongside people and their representatives to ensure these plans were personalised to their wishes and. The majority of risks to people’s health and wellbeing were managed safely with clear robust risk assessments and guidance for staff to follow. There were a small number of examples where further clarity was required to ensure guidance was always detailed and specific enough. However, all staff we spoke to were extremely knowledgeable about the people they supported and could clearly communicate how they would respond to ensure their safety. They had undertaken training around people’s specific needs and their knowledge regularly checked through supervisions. People had a consistent staff team who knew the risks to people and how they should be managed. The provider took prompt action to ensure enhanced guidance was put in place in the examples we identified to ensure this was sufficiently clear, for example if new staff were to start working with people and were less familiar with their needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were regular assessments of the environments people lived in to ensure any risks to people were identified and any appropriate actions taken. This included daily walk throughs checks and regular audits to ensure people were living in environments that were safe and well maintained. There were clear business continuity arrangements of how the provider would respond to any unforeseen circumstances that may put people at risk such as a fire or loss of important utilities. There were regular fire drills and clear person-centred guidance for staff on how they would support people to evacuate safely.

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. We found there was a stable and consistent staff team who were knowledgeable and trained to meet the needs of the people they supported. Staffing levels were regularly assessed to ensure they were sufficient to meet people’s needs, and there were regular supervision and competency checks to check staff maintained an upto date knowledge and were able to care for people safely. There were robust and safe recruitment processes with appropriate checks were undertaken to ensure staff being employed were fit and proper persons to work with vulnerable adults. People and their relatives told us that they were happy with staffing levels at the service with one relative stating “There are plenty of people about, lots of staff floating around, staff could be quickly relieved if they were needed elsewhere. My relative have a good set of carers, generally we’re very pleased.”

Staff also told us they felt staffing levels at the service were safe, and that they were given ongoing support including upon joining the service so they were able to understand people’s needs and be able to provide safe care and treatment. One staff member explained “My induction was seamless. We had time to go through care plans and meet people prior me starting to provide care. There was lots of E-Learning, which really helped, equipped and empowered me. I feel the training helped me get to know people really well.”

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. All staff had completed infection prevention training and had a good knowledge of how they would protect the people they supported from infections. Staff knowledge in this area was regularly checked by management. Where people were at greater risk of contracting infections through medical devices such as catheters or stomas, staff were knowledgeable about how to support people in managing these safely and the signs of infection to look for. One staff member told us “Yes, we have all had online training from the stoma nurse. Although we encourage the person I support to manage this independently, we have a support plan to help them including signs of infections to look out for. There’s a checklist we follow when observing them to change the bag to assess any signs of infection. So we give (person name) autonomy, but staff are there as a safety net and to support them in understanding how to manage it safely.”

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. We found medicines were administered by competent and knowledgeable staff, and there was clear documentation that ensured people received the medication they needed, when they needed it. Medication was safely stored and recorded, and people were involved in managing their own medicines in a way that was safe and respected their consent to make decisions. For one person staff told us, “They are very specific on what order they would like to take their medications, we respect this. They take them independently just need our help dispensing them. If they need their inhaler I will guide them through their breathing to ensure they get the relief they need”. There was clear guidance on when to give “as and when” medication, however the outcome of this medication and whether it was effective was not being recorded. We raised this with the provider who updated their paperwork to ensure there was now a space to record this.