Archived: My Life Choice

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• 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of the legal regulations relating to safe care and treatment and safeguarding.

This service scored 34 (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 demonstrate a proactive and positive culture of learning in order to improve people’s safety. People who used the service required specialised support to manage the risks they posed to themselves and others. The provider’s processes for managing incidents failed to identify and analyse trends and themes in order to minimise risks to people and staff.

For example, where staff were regularly using physical interventions to support people during incidents, the provider had recorded the risk posed and what physical intervention was used but did not investigate why the incidents had taken place. There was no detailed analysis into how staff were providing support or what had happened prior to the incidents. This meant the provider had not investigated the context of the incidents, including whether incidents were occurring more frequently depending on the staff present and their experience, skills and competency. The provider had not consistently completed debriefs with people and staff to understand what had happened and discuss possible changes to people’s support to minimise the risk of a reoccurrence.

Lessons learnt were not always documented and those in place lacked detail. For example, a review of 1 person’s incident reports for March 2025 noted they had ‘Displayed self-injurious behaviours on 85 occasions’. No learning or proposed changes were recorded. This meant the provider was not able to demonstrate how they were working to minimise the risk of incidents, reduce restrictive practices and improve people’s safety.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care when people moved between different services.

For example, where people needed to spend time in hospital, the provider had not always ensured people had support from a consistent staff team who knew them well and understood their individual needs and preferences. Care plan documentation was not always transferred with the person to ensure staff and health professionals had important information about how to promote people’s communication and independence during their stay. We received mixed feedback about how well the provider shared information and updates with people, relatives and health professionals when people were receiving support from different health services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve this. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. Relatives told us people did not always feel safe.

During the inspection, we saw incident reports which documented people making allegations of abuse against the staff supporting them. We found the provider had failed to respond appropriately to these allegations. For example, there was no evidence of any immediate actions taken to safeguard people and no safeguarding or CQC notifications had been raised at the time of the allegations being made.

People did always have guidelines or risk assessments in place to provide information about how to respond to allegations of abuse against staff. Where risk assessments and guidelines were in place, these were not sufficiently detailed or personalised. We also found evidence they were not being consistently followed. For example, on 1 person’s ‘allegations log’ we found no details recorded to evidence immediate actions taken following an allegation of abuse.

We found some incident reports relating to unexplained bruising, self-injury and physical interventions, which were available on day 1 of the inspection, had been removed from the provider’s live incident reporting system on day 2 of the inspection. At the time of the inspection, the provider was not able to explain why these incident reports were no longer on their system. This meant there was no evidence of action taken to investigate these incidents or safeguard people from the risk of harm and abuse.

The provider had not raised safeguarding concerns related to escalating or repeated incidents of self-injury to the local authority, in line with their own incident response policy. This meant it was not clear how the provider was sharing concerns with relevant health professionals to safeguard people from the potential risk of harm.

The provider did not work well with people and those important to them to understand and manage risks. The provider did not effectively share information relating to escalating risk with other health professionals to ensure people were supported to minimise risks to themselves and others.

People did not have risk assessments in place to manage all risks to their safety. For example, 1 person was at risk of ingesting non-edible items. We found they did not have a choking risk assessment in place to provide guidance on what staff should do in the event of a choking incident. Another person had a stoma in place. We found they had no specific risk assessment in place to provide guidance for staff about the risks and management of their stoma care.

Where risk assessments were in place, these were not sufficiently detailed to provide staff with guidance about how to support them safely. For example, 1 person had epilepsy. Their epilepsy risk assessment provided no information on how their seizures presented, when their last seizure was, or what action to take in the event of a seizure. This meant staff did not have appropriate guidance in place about how to support them safely.

The provider had not considered how to manage risks to ensure people were still empowered to lead full lives. For example, 1 person only regularly went out into their garden or onto the street they lived on. Staff told us this was due to the potential risks the person posed to themselves and others. The provider was not able to demonstrate how they were reviewing these risks or supporting the person to progress and engage in more meaningful activities.

The provider did not always detect and control potential risks in the care environment. Where people were at risk of self-injury, care plans and risk assessments did not always provide detailed guidance about how to manage environmental risks whilst promoting people’s privacy and dignity. Incident reports evidenced people had used items within their home environment to self-harm. It was not always clear whether these risks had been identified prior to incidents taking place. Damage to people’s homes had not always been promptly repaired to mitigate risks to people’s safety.

The provider had not always made sure appropriate equipment was in place to support the delivery of safe care. For example, at the time of the inspection 1 person did not have a hoist in their home despite requiring a hoist to support their mobility. Following the inspection, the provider confirmed a hoist was now in place.

The provider had not ensured all staff had the appropriate skills and competency to support people safely. At the time of the inspection the provider’s training matrix listed training relating to ligatures, self-harm, autism, personality disorders and sensory awareness as additional training which was not mandatory. This meant not all staff had been provided with specialised training to understand the specific needs of the people they were supporting. At the time of the inspection, only 26 of the 174 (15%) staff employed were recorded as having completed ligature training. Only 56 of the 174 (32%) staff employed were recorded as having completed self-harm training. This meant people were receiving support from staff who were not appropriately trained.

People were not always supported by a consistent staff team and we received mixed feedback about how well staff knew people’s support needs and preferences. Comments included, “They change all the time”, “You turn up and there’s a new face, there’s no stability in the staff”, “[Person] has regular staff now. At first, they didn’t. [Person] didn’t know who they would wake up to” and “One or two do [know person well]. Some are very poor. They’re just there to supervise [person].”

Staff were safely employed with appropriate recruitment checks in place and completed.

The provider did not always manage the risk of infection safely. Whilst we did not find concerns during our visits to people’s homes, relatives told us food hygiene practices were not always safe and people’s homes were not always kept clean. This increased the risk of infection. Comments included, “There’s out of date food in the fridge, the home is filthy”, “[Person’s] food was left in the open, not covered up and there were flies about”, “The food storage is an issue, fresh fruit is put next to meat”, “It’s a brand new house but there are mould problems because it’s never ventilated” and “I cleaned [person’s] bathroom. I said to staff, you know there’s a cleaning rota.”

The provider did not make sure people’s medicines and treatments were always managed safely. Relatives told us they had concerns about the administration of people’s medicines. Comments included, “There have been many occasions when no one can administer the medicines”, “I witnessed them about to administer the wrong medicines. They didn’t look right. They’d mixed the crushed and dispersible tablet together”, “[Staff] gave the meds, but they drew up the wrong amount and gave 5mls, not 10. I told [staff] to look at the label, it says two 5ml spoons”, “They haven’t sent medicines with [person] to hospital” and “There were a few medicines missed, so they are onto that now”.

The provider had not ensured staff trained in medicines management were always available to support people as and when required. For example, 1 person’s medicines risk assessment directed staff to refer to medicines trained agency staff if available or to contact the on-call manager. This meant there was a risk people may not receive their medicines promptly when required.

During the inspection, we carried out checks on people’s medicines stock and found medicines were correctly counted and recorded. However, we found protocols were not always in place for as and when required [PRN] medicines. This meant staff did not have guidelines to follow about how and why the medicine may be administered. We found 1 person had been given a PRN medicine to support them in managing their distress. However, no protocol was in place for staff to follow and there was no entry on the medicines administration record to explain why this medicine had been given.