HF Trust Hythe

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 inadequate. 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.

People’s care records had not always been followed or completed consistently. Therefore, we could not be assured that all relevant information regarding people’s safety had been reported to the management team. Although risks to people had been assessed and mitigated, we could not be assured that guidance was always followed by staff to ensure people’s risks were reduced. Records showed that some people’s medicines had not always been managed safely. Guidance had not been consistently followed in relation to the monitoring of a person with a specific health need. Therefore, we could not be assured that records were accurate.

Information was available when people moved between services. People felt safe with staff and knew what to do if they had any concerns or worries. Staff had been trained and knew the action to take if they had any concerns. People were supported to maintain a safe and clean environment which had been adapted where required to meet people’s physical needs. There were enough staff to ensure people received their commissioned hours of care and support.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety. The provider could not be assured that all incidents and accidents had been recorded due to some significant gaps in people’s daily notes. Without consistent or complete information, the service was not able to effectively monitor and act where required.

Where accidents and incidents had been recorded systems were in place to ensure these were fully investigated and action was taken when any lessons were identified. Records showed that following an incident the persons care records were reviewed, updated and a referral was made to an external healthcare professional. Any changes identified through patterns and trends were disseminated to the care staff during team meetings, handover meetings and at individual one-to-one supervision to support learning.

One person gave an example of a learning experience they found helpful. They told us they had attended a session in relation to moving and handling alongside their staff team.

People were involved in the transition between services. Individualised tailored support had been obtained with support from staff, relatives and external healthcare professionals. People were supported with a transition plan which included visits to the service as well as ensuring the house and their bedroom was personalised to their hobbies and interests.

People had hospital passports in place which contained important information about the person and their health needs to share with health professionals if the person was required to visit hospital to support a safe care pathway for them.

People told us they felt safe with the staff and felt confident to raise any concerns they may have if something was upsetting them. A person said, “I don’t have anything to worry about.” Relatives felt their loved one was safe with staff who knew them well and understood their needs.

We observed good, humoured interactions between people and staff which helped people to relax and feel comfortable and safe.

Staff had been trained, understood the potential signs of abuse and knew the action to take if they had any concerns. A member of staff said, “Making sure the people we support are safe and not at risk. Safeguarding is massive to me.” Safeguarding was discussed at each staff supervision and team meeting.

Staff had access to the providers policy and procedure in relation to safeguarding and whistleblowing.

There was a national safeguarding lead for the organisation for any safeguarding concerns. An initial report would be sent to the manager who would read this on the database. The safeguarding lead would then assess and pass on any actions to the manager for completion. The management team had access to the safeguarding leads for any advice or support that was required.

Processes to assess potential risks to people had improved since the last inspection, but there remained areas where further improvement was required.

Risks relating to the health, safety and welfare of people had been assessed but there was inconsistent evidence staff were following this guidance to keep people safe. Some people had been assessed as at risk of choking and needed specific support to eat safely. One person’s eating and drinking assessment was meant to have been reviewed 2 weeks previously but this had not occurred. Therefore, the provider could not be assured the guidance staff were following continued to keep the person safe. Another person needed individualised support to mobilise safely due to risk of falling and support to ensure their personal care needs were met. However, staff had not recorded how this person had been supported with these risks or any other aspects of their care for significant periods of time including for 4days out of 7during the week of 19 November 2024. Without accurate records of people’s crucial daily care, people were at risk of not having their needs met. Staff knew people well and spoke about the potential risks posed to people they supported. People and staff knew the action they took to mitigate these risks.

People were supported to live in a safe environment. One person had been supported to raise their housing concern regarding the redecoration of their house with the housing officer. Another person told us their kitchen work surfaces had been lowered to meet their needs, which enabled them to participate in the cooking of their meals.

Health and safety checks and audits were made on a regular basis to ensure the environment was safe. Staff had been trained in subjects such as fire safety, basic first aid and slips, trips and falls to promote safety within each supported living service. Equipment such as wheelchairs and moving aids had been checked and serviced on a regular basis to ensure they were fit for purpose.

People spoke highly of the staff who they knew well. Relatives told us they felt there were enough staff to meet their loved ones needs and that staffing levels had improved recently. Staffing rotas were clear and showed people had been allocated staff to their commissioned hours of support. The management team had worked alongside the funding authority when a persons’ needs had changed, and this required a review of their commissioned hours with the local authority.



Staff told us they received a comprehensive induction including working alongside experienced staff, getting to know people’s needs and undertaking essential training before working with people. Staff felt the training they had received covered their role and met people’s needs including their specific needs such as, diabetes and epilepsy. Staff received regular supervision with their line manager which staff said they found beneficial.



Staff told us the staffing levels had improved, and several new staff had started which had improved people’s continuity of care. The management team told us there had been a significant reduction in the use of agency staff since the last inspection which had shown a positive impact on the quality of care. If agency staff were required a skill match and induction were completed prior to any care shift and agency staff used were consistent to ensure the person knew them. Staff had been recruited safely.

People told us they were supported to keep their house and bedroom clean and tidy. People living within the shared supported living services had set days for cleaning and doing their washing. We observed the supported living setting to be clean throughout when visiting.

Staff had undertaken training in how to minimise the spread of infections.

The provider had systems and processes in place to assess and manage the risk of infection. For example, checks were undertaken on the cleanliness of people’s homes.

Medicines management had improved since our last inspection.

Staff told us they could identify if a person who had diabetes had a low blood sugar level that required additional medication as their blood sugar levels were checked and recorded regularly throughout the day. However, we found gaps in the recording of one person's blood monitoring scores. This had not had an impact on the person.

People told us their medicines were kept in their bedroom and that staff gave their medicines to them. The temperature of medicines was monitored to make sure they were safe to use. People, if able were supported to be independent with part of their medication giving them control and developing their independence. One person took their own blood monitoring scores which they then informed staff who supported them to manage their insulin.

Staff who administered medicines had received training and had their competency checked. When medicine errors had occurred, health advice had been sought and the relevant authorities notified. To minimise the risk of any recurrence, staff had been retrained, and their competence reassessed before recommencing with this role.