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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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems for managing incidents had now improved. Staff told us lessons learned were shared through team meetings and day-to-day discussions to help improve the quality and safety of care. The provider had systems in place to monitor incidents and identify patterns or trends. Managers regularly reviewed incident information and told us they sought support from appropriate professionals if any concerning trends were identified.

Relatives told us communication following incidents had improved and they were kept informed when concerns arose. One relative said, “I feel much happier that my loved one is receiving better support and there is an openness and transparency. Incidents are reported such as medication errors and what is being done to make sure that it does not happen again. This gives me confidence that my loved one is safe.”

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.

Safe systems were now in place to monitor and record people’s health, and staff had routinely updated people’s health records.

Hospital passports were now current and included relevant information including Speech and Language Therapist (SALT) eating and drinking guidelines and important signs people used to communicate their needs. Referrals were made to relevant health professionals, for example wheelchair services and physiotherapy.

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. The provider shared concerns quickly and appropriately.The provider now routinely shared safeguarding incidents with CQC and the local authority.

We observed people appeared to be treated well and there were no observed safeguarding concerns or signs of a closed culture. Staff were quick to respond to people who were at risk.Relatives felt people were safe.

Up until June 2026, people could only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions. They had choice, control and freedom over their lives.

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

People’s care plans had improved and accurately reflected their current needs and circumstances. Risks were assessed appropriately and staff had clear guidance on how to support people safely.

Relatives told us they were involved in planning and reviewing people’s care and support. One relative said, “If there are changes to the care plans, I am asked for my opinion. Any change is monitored to make sure it suits my loved one.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Improvements had been made since our last assessment, previously, we identified a number of trip hazards in the garden. At this assessment, we found the provider had taken action to reduce these risks by installing ramps and handrails, making the outdoor area safer and more accessible for people. The provider had also improved the security of potentially hazardous items. Cupboards containing substances hazardous to health (COSHH) were securely locked to reduce the risk of unauthorised access.

Effective systems were in place to monitor the safety of the environment and ensure any identified risks were addressed promptly.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

At our last assessment, we found the provider had not always effectively assessed or managed infection prevention and control risks. At this assessment, we found improvements had been made. For example, risks associated with the use and maintenance of the jacuzzi were now being appropriately managed.

The home was clean, well maintained and free from unpleasant odours. We observed staff following good infection prevention and control practices, and records showed routine food safety checks were now being completed.

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.

In the last assessment the provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. In the previous assessment medicines needing additional safe storage had not been managed correctly in the service and documentation relating to management of topical patches was not always completed by staff. In this assessment we identified improvements had been made to medicines management. Although there were no medicines requiring safe storage in the service the provider had updated peoples risk assessments where appropriate to ensure the staff would have the correct information in the future about the use of topical patches requiring safe storage. Staff were now aware of the documentation that would need to be completed if people were prescribed topical patches which required safe storage.

The provider had now ensured documentation relating to people’s medicines was accurate. Care plans included details of all medicines prescribed, not only oral medicines. How people liked to take their medicines was also included in care plans to support staff to take a person-centred approach to medicines support.

The provider had updated Personal Emergency Evacuation Plans (PEEPs) to include risks associated with prescribed paraffin-based emollient creams. This helped ensure people could be evacuated quickly and safely in the event of a fire. Staff were aware of these risks and how they could be mitigated.

Medicines records were now completed appropriately. We saw no gaps in administration records during this assessment. Where people had medicines prescribed to be taken “as required” or “PRN”, protocols were in place to support staff to administer these medicines as prescribed.