80b Randall Avenue

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.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 84 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Staff described a positive and proactive approach to learning and addressing concerns, underpinned by a culture of openness and responsiveness. They expressed confidence in raising issues, knowing that management would respond promptly and appropriately. One staff member explained, “We hold management meetings to discuss client-related concerns, followed by team meetings and intervention planning. We also use a WhatsApp group to share updates and raise any immediate issues.” Weekly management meetings were seen as a key mechanism for reviewing service challenges and implementing actions that drive continuous improvement.

Staff also highlighted management’s receptiveness to feedback and new ideas, fostering an environment where contributions are welcomed and valued. A team member noted, “There is MDT working… they listen when we have ideas,” reflecting a collaborative, multidisciplinary approach that supports shared learning and innovation. Another added, “We have team meetings every week… there’s an agenda and a wellbeing check-in,” pointing to structured opportunities for reflection, open dialogue, and emotional support. The daily presence of management further reinforced a sense of accessibility and trust, key ingredients in sustaining a dynamic learning culture.

This commitment to learning was also evident in leadership practices. The deputy manager demonstrated transparency in responding to feedback from a local authority monitoring visit, providing clear evidence of actions taken to support service improvement. The provider routinely conducted audits, addressing any issues identified in a timely manner. Client surveys were also used to gather insights and inform ongoing development.

Feedback from relatives further reinforced this. A relative shared, “Overall, I am quite impressed with the service. They do respond very well, even brought the complaint back to the relative, explaining how it was dealt with.” This reflects the provider’s dedication to learning from feedback and embedding good practice across the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider had established good community and partnership relationships, contributing to a supportive care environment. The care plans and risk assessments we reviewed were up-to-date and included relevant information reflecting people’s health and social care needs. This ensuring the continuity of care, particularly during transitions between services, helping to maintain consistency and support for individuals.

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.

Staff we spoke with showed strong safeguarding knowledge and were confident in both internal and external reporting procedures. They demonstrated a clear understanding of Making Safeguarding Personal (MSP) principles, placing emphasis on individual outcomes and supporting people’s choices. A staff member explained, “We need to be effective in supporting clients when it comes to abuse. We have policies in place, and we consider mental capacity,” while another added, “Our procedures and policies are clear.” These comments reflect a well-embedded safeguarding framework that is understood and applied consistently across the team.

The provider had up-to-date safeguarding and whistleblowing policies in place, and staff training compliance in safeguarding was at 100%, evidencing a strong commitment to maintaining a safe and responsive care environment.

People using the service told us they felt safe, and relatives we spoke with shared this view. A relative shared, “I do feel my relative is safe. They’re quite strict about being at the service on time for medication, they take it seriously.” This feedback highlights a culture where staff are attentive to people’s needs and follow clear procedures to protect their health and wellbeing.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People using the service confirmed that staff regularly reviewed care plans with them, ensuring their views were heard and reflected. One person shared, “They are good, they will sit me down and talk things through with me.” People who used the service told us they are offered copies of their care plans, reinforcing transparency and shared ownership of their care and managing risks. The care plans and risk assessments we reviewed included people’s perspectives on how risks should be managed, with decisions made collaboratively to promote independence, choice, and control.

Relatives also spoke positively about the service’s approach to risk. One commented, “Staff safeguard them so they feel more comfortable, and they get more assessments done so they can understand needs and triggers.” This feedback highlights the service’s commitment to tailoring care around individual risk profiles.

A staff member told us they aim to “stay one step ahead,” and shared examples of how they anticipated and responded to individual needs. For example, when informed that a person’s relative was passing, staff recognised the potential emotional impact and implemented bereavement support to help the individual process their feelings. This was done in consideration of their mental health and its influence on their recovery path and care plan. A staff member noted, “Management have really seen the need and responded well,” to bereavement support, reflecting a responsive and empathetic culture.

The provider had a robust accident and incident reporting policy in place, accessible to all staff. Staff we spoke with demonstrated a clear understanding of the procedures for recording and reporting incidents, and described the systems used to ensure timely and accurate documentation. This structured approach supported a safe environment where risks are actively monitored and addressed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. A person who used the service told us, “The environment is good,” while a relative shared, “The communal areas are spotless,” and added that they felt safe when visiting. During our observations of 2 services, the services were found to be appropriately furnished and equipped to meet the needs of the service user group, contributing to a safe and comfortable environment.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

There was a strong commitment to safe[WP1] collaborative multidisciplinary team (MDT) approach. Staff we spoke with spoke of a positive team culture, describing a strong ethic of working together. One staff member shared, “Staffing is sufficient,” while another commented, “The best thing about working in this service is the teamwork,” reflecting a well-supported and cohesive workforce.

Staffing levels observed during visits to 2 supported living services were appropriate and responsive to the needs of the people being supported. The provider had a dedicated therapies team that delivered a range of activities tailored to individual preferences and goals.

The provider had an in-house counsellor who offered flexible support to people using the service. Counselling sessions were not restricted; people were reviewed every 6 sessions, but continued support was available if both the counsellor and the individual felt it was necessary in achieving their goals. The counsellor worked closely with the wider team, attending both management and team meetings to ensure integrated care planning. In addition to direct support, the counsellor contributed to staff development by delivering in-house training on topics such as Autism, helping staff better understand and respond to diverse needs.

Mandatory training records showed that staff received ongoing training appropriate to their roles, including specialist training in mental health. The provider had also accessed additional training opportunities through the local authority for staff, including sessions on dementia.

Supervision records confirmed that staff had regular one-to-one meetings with management to support professional development and identify further learning needs. Systems were in place to monitor training and supervision, ensuring staff remained up to date and equipped to deliver safe, effective, and person-centred care.

We reviewed 3 staff recruitment files and found that all appropriate processes and checks were in place. The service conducted enhanced Disclosure and Barring Service (DBS) checks, which included details of any convictions or cautions held on the Police National Computer. This information supported the provider in making safer recruitment decisions.

[WP1]a safe, collaborative

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. The provider had an up-to-date infection prevention and control policy in place. During our observations of 2 services, the environment appeared clean and well-maintained, with hand sanitiser readily available at the entrance to promote good hand hygiene practices.

A relative we spoke with told us, “Clothes are folded nicely, bins emptied, main kitchen area is clean, I cannot fault it.” This reflecting a positive impression of the service’s cleanliness.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People we spoke with who used the service shared that staff supported them with their medication, while others reported being independent in managing their own medication. They also noted that the service had helped them work towards independence with taking their medicine.

Staff had received training in medication administration, and their competency was reassessed annually to ensure safe practice. We reviewed 1 service’s medication audit, which was up to date, and looked at the medication administration records (MARs) for 3 people. No gaps were identified, providing assurance that medicines were being administered safely and as prescribed.