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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 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 regulation in relation to safe care and treatment, especially in relation to medicines.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager did not promote a proactive or positive safety culture based on openness and honesty. Lessons were not consistently learned or embedded to drive good practice. While accidents and incidents were recorded, the quality of these records was poor. Documents were not kept in chronological order and many lacked details about the incident, the actions taken, and the lessons learned.

In addition, body map forms had been completed to highlight redness, sores, or bruising, but there was no associated incident form, so the records were incomplete. Behaviour charts were also in place for some people, but these were poorly completed and did not record the support or reassurance provided.

Although the registered manager said, “The seniors do an audit monthly (of the accidents and incidents)” no evidence of these audits could be found. The registered manager later confirmed that no audits had been carried out so far this year. This meant there was no oversight of patterns or trends in accidents and incidents. It also meant the registered manager was unable to demonstrate how lessons were learned or what changes had been made to reduce future risks.

Some positive actions were taken in response to incidents. For example, one person’s falls risk assessment was updated and another had their bed lowered with a sensor mat installed to alert staff if they got up during the night.

The registered manager did not always work effectively with people or healthcare partners to establish and maintain safe systems of care, as the pre-assessment process lacked robustness. For example, 1 person was admitted to the service following an assessment by the registered manager, but it became clear that their needs could not be met. As a result, the person had to move to another, more suitable service. This caused them distress and anxiety, as they had already settled into Ridgegate Home. The registered manager acknowledged this, saying, “If I’d known what I know now, I wouldn’t have accepted [person]. The staff aren’t trained in relation to looking after people with (this health condition).”

In contrast however, other people had the opportunity to spend respite periods at the service before making a decision about moving in permanently, which enabled them to have a smoother transition into the service.

The registered manager did not consistently share safeguarding concerns promptly or appropriately with the relevant authorities, despite telling us, “I am aware of what I need to report.”

We reviewed body maps that showed at least 3 instances of unexplained marks or bruising on people, yet these had not been reported to the local authority safeguarding team as potential concerns. The documentation itself was poor, lacking sufficient detail about the injuries, possible cause or any follow-up actions taken. In addition, the registered manager described an incident where a staff member shouted at a person, but this was also not reported. We also read of an occasion where 1 person shouted at another, which again was not fully recorded or reported.

This demonstrated poor record-keeping and ability to recognise potential abuse. As a result, neither the registered manager nor the provider could be assured that people were being protected from the risk of intentional harm.

Staff undertook safeguarding training and understood they had a responsibility to report any safeguarding concerns. One staff member told us, “We’ve done quite a few courses. I would report to the line manager or [registered manager]. I’ve never seen anything of concern.”

Relatives felt their family members were safe, with one telling us, “I trust them and I don’t think he will be harmed from anything.”

In contrast, following a serious safeguarding concern at the beginning of this year, senior management was able to demonstrate the actions they took to investigate and respond to this. This included working with the local authority safeguarding team, a social care consultant and making the decision to dismiss some staff members.

The registered manager did not always work effectively with people to understand and manage risks, meaning safety was not consistently maintained across the service.

We reviewed the personal emergency evacuation plan (PEEP) folder for the service, which should contain up-to-date information about how each person would be supported in the event of an emergency, such as a fire. Although the folder had been reviewed in March 2025, it included a PEEP for someone who no longer lived at the service and was missing PEEPs for 2 people currently living at Ridgegate Home and who had moved in after the date of the review.

Other documentation was incomplete, out of date or missing. One person had a ‘slips and falls”’ risk assessment in place, but it was undated and had not been reviewed making it unclear whether or not it was current. The same person’s profiling bed risk assessment had been written in May 2024 but had not been reviewed or updated since. Another person was recorded as having Type 2 diabetes in some medical notes, but this was not reflected in their nutritional care plan and a third person had no nutritional care plan in place despite being on a modified diet. Although most people using pressure-relieving mattresses had them set to the correct weight, 1 person’s was set at 10kg over the setting it should be meaning the effectiveness of the mattress would be compromised increasing the risk of this person’s skin breaking down.

In some cases, appropriate measures were taken to manage risks. For instance, where people were at risk of falling out of bed, crash mats were used which helped to reduce the risk of injury. Also, for a person who needed to be hoisted, there was clear guidance on which sling to use, how to use it and where staff should stand to ensure safe transfers. Other care plans contained detailed information. For example, 1 person’s falls risk assessment included instructions to keep their environment clear, ensure their call bell was within reach and check their wheelchair was in good working order with footplates correctly positioned.

People lived in an environment that was checked for its safety. Equipment checks were carried out regularly and where one hoist was deemed unsafe, this was replaced by the provider. Gas safety and fire checks were completed and electrical items tested for their safety and compliance.

People were provided with equipment to support them to move around the building safely, such as a Zimmer frame, and where people stayed in their room they were provided with a call bell or a personal alarm.

However, staff told us they had not received sufficient fire training. One staff member said, “If the alarm went off the doors would be shut, but we haven’t done a fire drill.”

Although the registered manager ensured there were enough qualified, skilled, and experienced staff, supervision and further development were not consistently provided.

Whilst we found no concerns about staffing levels and people told us they did not have to wait for care, staff were not receiving the level of training and support they should expect. Staff told us that supervisions and appraisals were not taking place. One member of staff said, “I haven’t had one supervision.” Another told us, “I am due one. Nothing gets done here.” The registered manager acknowledged this, stating, “I am behind on supervisions. I’ve done some but appraisals have moved to our new HR system so I need to start those.”

We also found that some staff lacked essential training. For example, the chef had not received training on the International Dysphagia Diet Standardisation Initiative (IDDSI) which is important for supporting people with swallowing difficulties, or for people on a modified diet.

We observed a sufficient number of staff on duty on the day of our visit and observed no one having to wait for care. We also reviewed the call bell logs and saw that call bells were answered promptly by staff. One relative told us, “I think so (there’s enough). I really do.”

Staff were recruited through a robust process which included them providing evidence of their performance in their previous role, their right to work in the UK and their fitness for the role. Prospective staff underwent and Disclosure and Barring Check (DBS) prior to commencing work to ensure they were suitable to work in this type of setting.

The registered manager assessed and managed infection control risks. We found the service to be clean and hygienic, with housekeeping staff working throughout the day.

However, we identified some areas for improvement. For example, continence pads were left out of their packaging in 1 person’s bathroom and the kitchen floor required cleaning. Leaving continence pads in their original packaging protects them from dampness and other environmental factors, ensuring they remain dry and effective.

However, feedback from people and relatives about the cleanliness was positive. One person said, “My ensuite toilet and sink are cleaned every day” and another commented, “My bedsit is clean and tidy.”

We also found at lunchtime, staff wore appropriate personal protective equipment (PPE), including gloves and aprons, which helped prevent the risk of cross-contamination, particularly as some people required support with eating.

The registered manager did not always make sure that medicines administration and practices were safe. Although a relative told us, “Amazingly well looked after (in relation to their medicines)” we found poor systems and practices were in place.

One person’s medical notes confirmed they were allergic to a particular medicine, but this information had not been transferred to their medication care plan. Topical creams (medicines in cream format) were not always applied in line with the prescription. For example, 1 person was prescribed cream to be applied 3 times a day, however, records showed that during August it was only applied once on 11 occasions, twice on 4 days and not at all on 2 days.

Record-keeping for ‘as and when’ (PRN) medicines was also poor. Staff were not consistently recording the reason for administering PRN medicine and protocols lacked sufficient detail, stating ‘pain – when required’ without specifying what type of pain or how often the PRN medicine should be given.

Several people were being given PRN medicine regularly. For example, 1 person was given their PRN medicine daily between 9 and 21 August, however no reason was documented in their notes. Three other people were also given their PRN medicine several times a day but there was nothing in the records to indicate why. Although staff told us the information was written in people’s daily notes, our review of the August records did not confirm this. The staff had not considered that someone needing their PRN medicine regularly may indicate that their care needs had changed and as such their GP should be asked to review their medication plan.

Documentation relating to pain patches was unclear and staff told us the thermometer used to monitor the temperature of the storage was unreliable which meant staff could not be assured they were storing medicines in line with the manufacturers guidance. Where staff had given half a tablet to a person they were not recording they had only given a half and in some cases, medicine administration charts (MARs) had been hole-punched through people’s surnames covering up important information.

Only trained staff administered medicines; however not all staff had had their competency assessed. One staff member told us, “No, not yet. I came here with my training online from the agency. I need to do theirs (providers training).” The registered manager confirmed this telling us, “We haven’t done competencies yet. It’s on my list.”

We did however find MAR charts included dated photographs of people, details of any allergies, and GP contact information. There were no gaps in the medicine MARs we reviewed and a sample count of medicines showed the records were accurate.