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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 inspection, we rated this key question as good. At this inspection, the rating has changed to requires improvement. While people did not raise any concerns in relation to their care and safety, some concerns were raised by relatives and professionals. Further improvements were needed to the way the service analysed incidents and accidents, some of the provider’s policies, the safe recruitment process, people’s records of care delivered and the way people were supported to maintain their environment to be clean and safe. Most of these concerns were known to the provider and the service had an action plan. Further time was needed for the provider’s actions to be embedded and sustained so we can judge the impact they have on the quality of care people receive. The service had care plans to support people to manage their risk and the service used strategies to prevent distress to people. Reactive strategies for individuals were available and followed by staff, so they consistently supported people when they became distressed.

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.

Lessons were not always learnt to continually identify and embed good practice. The service did not have a system to effectively analyse incidents and accidents for trends and patterns. The provider spent time mentoring staff to accurately and consistently record these on the electronic system. Managers were reviewing incident and accidents individually. We saw evidence that incidents started to be quantified however records did not always indicate these had been analysed for all possible trends, for example in relation to behaviour incidents. This meant opportunities might have been missed to use this information to minimise the potential risk to people from future accidents and incidents. The management team had planned to introduce a system going forward, however further time was needed to implement this process and judge its effectiveness.

The management team had been working with the local authority learning disability quality team to make the identified improvements to the service. During our assessment, the local authority informed us their work with the service had ended and congratulated the team for the progress they had made.

The service had sent feedback forms out to relatives and were planning to roll these out to staff and people. The managers told us the feedback received from these surveys was going to be used as part of a development plan which was going to be shared with the participants.

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. People had health action plans and health books. Through the care documentation we looked at, we saw evidence people were involved in planning their care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

We received mixed feedback from people’s relatives in relation to people’s safety. One relative told us they do not feel their loved one was safe being supported by the service. We also had some concerns shared in relation to the care and support some people received.

People we spoke with did not share any concerns in relation to their safety or the quality of the care and support they received.

The service had a safeguarding policy for both adults and children. We signposted the service to review this in reference to their safe recruitment practices.

The service had a safeguarding log with evidence staff reported safeguarding allegations and concerns to the local authority. However, many of these had not been reported to CQC.

Staff were aware of their responsibility in relation to safeguarding and how to report concerns and escalate outside of the organisation. Safeguarding training was being provided to staff.

The service was working within the principles of the Mental Capacity Act (MCA). People’s care documentation evidenced this.

The provider did not always work well with people to understand and manage risks. Staff did not always record that they provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not always fully maintain people’s care records. For example, some records were missing in relation to the support provided, particularly where people were supported on a 1:1 basis. This meant there was a risk the provider could not evidence care and support were delivered in line with people’s assessed needs.

We identified improvements were needed to people’s individual fire risk assessments for the properties they lived in to ensure the risk was robustly mitigated. The provider had engaged with the fire service which caried out a visit to 1 of the properties due to a recent fire. They were working on addressing the actions in this report and liaising with the fire service in relation to this work.

People did not share any concerns with us in relation to the quality of care received however, concerns related to people’s care and support needs not being met were shared by some relatives and professionals. We discussed these at length with the service manager. The management team were aware of concerns, and this was evident from their records. The service manager and nominated individual discussed with us the actions they were taking in relation to these. Additional assurances were provided by 1 person’s social worker.

The service had risk assessments for people to guide staff.

Where people had positive behaviour support plans, these were referenced within the risk assessments. Positive behaviour plans were red, amber, green rated with very clear descriptors for staff to identify and act upon.

Staff we spoke with knew people well and our observations of staff interaction with people evidenced this.

The provider was working on detecting and controlling potential risks in the care environment. They were in the process of making sure equipment, facilities and technology supported the delivery of safe care.

The service was working with the housing provider to support people to address any issues related to their properties. The service identified areas for improvement and actions were identified to control potential risks in people’s homes. The service had an action plan which included identified work that needed to be carried out to the properties. This included management to the risk related to fire safety and heating provision in 2 of the homes which required further improvement. Further time was needed to ensure all actions were completed and imbedded.

The provider did not always make sure their recruitment processes were effective and safe. The provider did not always make sure staff received their supervisions; however, they were on track to ensuring staff received this support. The provider ensured there were enough qualified, skilled and experienced staff. Staff were provided with effective inductions and training.

Improvements were needed to ensure staff were being recruited safely. This meant staff could be employed who were not safe to be supporting vulnerable people. There were gaps in recruitment checks. The providers recruitment policy was not in line with the requirements of the relevant regulation.

However, the new management team had reviewed all the recruitment folders and were aware of the shortfalls within these and were working on rectifying the issues. We looked at an example of a recruitment file completed since the new management team were in post and it was evident they were now following safe recruitment practices.

Some staff had not received staff supervisions. The management team were working to ensure all staff received a supervision. We saw evidence the number of supervisions leaders had completed had increased since July 2024.

There were enough staff to cover the commissioned hours. The management team had identified they required more staff who could drive people’s vehicles and were supporting some of the staff with this.

The training coordinator discussed with us the induction process for new staff which included training, shadowing an experienced staff member and a robust process of competencies, training and support for them during the probation period. We saw evidence of this in the staff folders that we viewed. Staff who were new to care were supported with the care certificate.

The new management team had reviewed and reorganised the training for all staff and where there were gaps, the training was planned or booked. Staff received a mixture of online and face to face training. Face to face training included medicines, positive behaviour support, fire safety and moving and handling. Training specific to support people’s individual needs was provided such as training in supporting people with a learning disability and autistic people. Staff were positive about the training and support they were receiving. However, we identified some improvements were need to the way completed training was recorded to ensure this was accurately and clearly recorded.

The management team had implemented a care audit system to test staff practice and knowledge. We saw evidence that some had been completed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We have identified some areas of poor hygiene, particularly in bathrooms, where people needed extra support with maintaining their environment depending on their needs either to carry out tasks by themselves or staff to support them. This meant that there was a risk of spread of infection.

Staff were completing cleaning schedules and health and safety audits however, these had not identified the areas we found where people required extra support. The manager had planned with people for a deep clean of all properties as they recognised this needed addressing. During our assessment, 2 properties had been deep cleaned.

The service did not have robust systems in relation to infection prevention control (IPC). The service had a risk assessment which had been reviewed by the new management team however, more detailed information was needed to ensure staff were supported to manage the risk of infection. The provider was working on introducing an IPC champion in the service and was in the process of developing the role description for this. We signposted the service to the local authority IPC team for support.

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

Care plans for people’s medicines did not always reflect their individual needs. For example, people with epilepsy did not have details about how to manage seizures in their care plan. When we spoke with staff, they were not always clear on the correct individual action to take in the event a person had a seizure. This meant that people might have not been supported in line with their individual action. in case of a seizure However, records showed that staff completed epilepsy training.

Where people were prescribed medicines that required additional safety monitoring, these had not been risk assessed. Additionally, staff were not aware of the risks associated with these medicines and how to mitigate these risks.

Not all people prescribed flammable topical emollient creams had the required risk assessments.

Some medicines, such as pain killers, were prescribed to be used “PRN” or “when required”. The service did not have protocols to support staff to make decisions about when these medicines would be required by people.

The service had a medicine policy. However, based on the evidence above, we were not assured staff always followed it.

The provider did take action to begin to address the issues identified with medicines during our assessment.

Medicines including controlled drugs were stored securely and safely at the homes we visited.We observed medicines were given to people in a person-centred and caring way.

Staff worked closely with healthcare professionals to resolve issues with people’s medicines in a timely manner. Staff supported people to attend appointment with healthcare professionals, including annual reviews.

Staff completed mandatory medicines management training and staff completed annual assessments to ensure they remained competent.