Bespoke Care & Support Services

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 regulations in relation to safeguarding, staffing and fit and proper persons employed.

This service scored 56 (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 mostly had a proactive and positive culture of safety, based on openness and honesty. The registered manager listened to concerns about safety and investigated and reported safety events, most of the time. Lessons were learnt to continually identify and embed good practice. There were processes in place to record and investigate accidents and incidents. Individual staff were involved in discussions to learn from incidents to prevent them happening again, but we found no evidence of regular staff meetings to share feedback. The registered manager told us staff were kept up to date when people’s needs changed, through encrypted group chat messages, but we were not provided with any meeting minutes or sharing of lessons learned.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The registered manager told us that service users were referred to other services if required, such as District Nurses and Occupational Therapists, and had good professional relationships

with them.

We reviewed evidence of a past incident where staff actions did not fully follow expected procedures, which could have left a person at risk of harm.

The leadership team responded promptly to the concern at the time and took appropriate actions. Learning was shared with staff to help prevent a similar incident from happening again.

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.

The provider had an up-to-date safeguarding policy in place and staff understood how to monitor for signs of abuse and how to report these appropriately. Staff received training in safeguarding although they needed training refreshed to ensure their knowledge remained up to date. The provider did not follow safeguarding procedures because they did not always report safeguarding concerns to the local authority and dealt with them internally instead of following the required reporting process. They had also not sent statutory notifications to the Commission.

People told us they felt safe. One person said, “Yes, I do feel safe, most of the staff are very kind.”

People knew how to raise a concern and felt assured that appropriate action would be taken by the provider.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans did not always provide sufficient guidance on how staff should safely support people. Staff were provided with daily tasks via an app which provided instruction on how to support people at each visit. Risks to people were not assessed and records did not show staff how to reduce risks, for example, people who were identified as at risk of falls or choking did not have a risk assessment in place at the time of the inspection. The registered manager advised actions would be taken. People who were at increased risk of skin breakdown did not have nationally recognised tools in place to guide staff in identifying deterioration in a person's skin, although a relative told us that a staff member did notice a sore on their partner and advised them to contact the GP. This was followed up by the district nurses. People had not been affected by the risks identified; however, we could not be assured the service had effective risk management in place and their audit systems had not been effective in highlighting these concerns.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

People were not fully protected from environmental risks because key safety assessments had not been completed.

Assessments identifying hazards such as animals in the property had been carried out, but there were no risk assessments around fire or potential evacuation plans for people and staff.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff did not always have the training needed to deliver care safely and competently. During the inspection, we found that some staff who regularly supported people had not completed the required training to meet people’s needs, particularly in practical moving and handling. We also found that several staff were working with training that had expired.

Staff gave us mixed feedback about the support they received, and evidence showed that only three staff members had an appraisal in 2025. Audits indicated that the leadership team were aware of this shortfall and had prioritised completing appraisals as a matter of urgency.

Staff were not always recruited safely. Records showed that some staff started work with disclosure and barring service (DBS) checks from previous employment, and the provider had not applied for new DBS checks when those contracts began. The management team told us that annual criminal-activity declaration forms were signed by staff; however, these were not present in all the files we reviewed. Risk assessments were completed where references were delayed, which allowed some staff to start work before all pre-employment checks were in place.

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. People and staff told us they had access to Personal Protective Equipment (PPE). The leadership team carried out spot checks regularly which identified some shortfalls, but these were actioned promptly to ensure compliance and staff were offered refresher training, if required. Policies were in place to support safe infection prevention and control practices.

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’s medication records were thorough and complete, including any allergies and potential medication side effects.

Medication times were clearly shown on the record, and staff used an app to log medication administration.

Staff were observed in practice by senior staff to ensure competency in medication administration, although some staff had expired medication training. We raised this with the registered manager who advised this would be addressed promptly.