Ailwyn Hall

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 remained Inadequate.This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safeguarding, risk management and the management of people’s medicines,staffing and recruitment of fit and proper staff.

This service scored 28 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Systems designed to investigate and reflect on accidents and incidents were not robust. Not all safety incidents had been fully investigated, and where they had been investigated, learning had not always been shared with all staff. Reflective accounts were not in place following incidents such as medication errors. During our onsite visits we noted residents entering other residents’ bedrooms multiple times. Staff did not always challenge this behaviour, and it was seen as an accepted situation by many. There was no further consideration about how to manage and reduce this to ensure people were safe.

Relatives told us they had raised safety issues but had not had a satisfactory response and remained concerned about their family members. One said, ’I did raise [an issue]…It’s not safe to leave [my relative] unattended. They said, “Yes, it should not be happening, I will feed that back’’… but I haven’t seen any difference.’

People who used the service experienced high levels of falls and of unexplained bruising. This had not triggered effective wider investigations to establish patterns, trends and identify any further measures which could be put in place to try to reduce them.

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

When we inspected the service,people were not routinely moving into theservice as the local authority had an embargo on placing peoplethere. The quality of information held by the service did not easilyfacilitatethe sharing of information with other health and care professionals as it was not alwaysaccurateor current.

Handovers did not always ensure key information was communicated about people’s changing needsand prompt referrals made toaddress new and changing needs.Referrals to specialist services were not always made in line with the provider’s own processes.

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

We identified that poor processes were in place to identify, report and manage safeguarding concerns at the service. Serious safeguarding allegations had been made against multiple agency staff. This was reported both to CQC and to the police. However, processes were not in place to ensure staff who were the subjects of an ongoing safeguarding investigation were prevented from carrying out further shifts. We identified four staff had continued to be booked to undertake shifts despite either being banned from working at the service or being allegedly involved in a serious and ongoing safeguarding investigation.

Following recent safeguarding concerns, the provider had reviewed their systems for booking and training agency staff. However, these new systems were not robust. We identified an agency staff member, who had never been at the service before, was providing one-to-one support for a person living with dementia. The staff member had not had their training or legal right to work checked, had received no induction, had not been introduced to the person they were supporting and were unable to tell us the person’s name, their needs or how they would summon help in an emergency. Poor processes at the service meant senior staff were not aware this staff member was in the building. This placed people who used the service at risk of abuse.

People can 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 found one person, who had bedrails fitted to their bed, had not had their capacity to consent to this assessed and the provision of bedrails subsequently agreed to be in the person’s best interests. This constituted unlawful restraint.

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

We identified risks were which were poorly managed. People had personal emergency evacuation plans (PEEPs) which set out how they should be supported to evacuate the building in an emergency. We viewed PEEPs for people whose mobility was very poor or who needed the use of a wheelchair. These PEEPs documented the need for staff to employ the ‘carry down method.’ This meant four staff, each holding the leg of a chair, should carry the person out of the service. There were not enough staff to use this technique and a local fire officer confirmed to us this was not an approved technique.

Risks such as the risk of choking, developing a pressure area and falls were not fully documented in care plans and not well managed. People were not repositioned in line with their care plan to reduce the risk of developing a pressure area and where people had been identified as being at high risk of falls, measures were not put in place promptly to address this. The use of high levels of agency staff increased risks as staff did not always know people well enough to support them to take managed risks. However, this aspect had improved slightly by the time of our fourth onsite visit as one page profiles of people who received funded one-to-one support had been put in place.

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

We identified some areas of the service which posed a risk to people. We observed items stored in a cupboard next to an electric fuse panel which posed a potential fire risk. A windowsill in one person’s bedroom required repair and posed a risk of splinters to people using that room. These were addressed by the time we carried out our third onsite visit on 12 February 2026.

We identified two areas which posed a trip hazard to people. One where an area of flooring had been removed and one where there was a slope. We also noted an area which was poorly lit and contained changes of flooring including one very dark piece of carpeting. This could have been processed by people living with dementia as a hole and created a further potential risk. The main stairway had a stairgate with keycode to prevent people accessing the upstairs level if they could not do this safely. However, the second staircase had a stairgate but no keycode and we observed a person who used the service accessing the upper floor using this staircase. The main staircase also had a low bannister on the first floor which presented a potential risk. This was remedied by the time our assessment process was concluded. A storeroom door opened outwards into a communal area and we observed it being opened while a person using the service was standing outside and the door hit them on the head. This poor design placed people at risk.

We observed that multiple unsafe items, including razors, were not locked away. We also found shaving gel, shampoo, shower gel, lip balm and toothpaste which posed a risk to people living with dementia who might believe them something to eat or drink. By the time we visited for the fourth time on 18 March 2026 this issue had been addressed.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Staff told us staffing levels were not adequate. One commented, ‘We are stretched at times, especially if something happens.’ Another told us, ‘We need more staff and more devices to care for the residents.’ They told us they had to share electronic devices to update care records. This improved by the time we undertook our fourth visit as more devices were purchased. Relatives we spoke with also commented on a lack of staff. One said, ‘I would often find no staff in here, maybe a cleaner, and I always thought it was a little off.’ Another commented, ‘My [relative] needed changing and there wasn’t anyone to take them. [My relative] was very distressed. I don’t know how long we waited but we waited long enough.’

Several staff commented on the length of time the medication rounds took as this meant senior staff were off the floor and unable to provide guidance and management of the shift for hours at a time. One told us the evening medication round can take over 3 hours, especially if new medicines were also required to be returned or booked in. Our visits confirmed medication rounds took approximately 3 hours on each occasion. On our first visit on 02 February the morning round ran into the lunchtime round.

Staff were not always safely recruited and, once employed, did not always receive appropriate induction and support. Appropriate references were not always in place to check staff’s previous work performance. One staff member had been recruited on a student visa which restricted their working hours to enable them to study. The provider was unaware of this and the person was working vastly in excess of their allowed hours.

Although staff received training, the majority being online training, some relatives questioned the skills and expertise of the staff. One relative shared concerns about the high use of agency staff saying, ‘I believe they know [my relative] 100%, the full time staff definitely. The ‘infills’ – no. The agency staff are not as attentive as the full time.’

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The service had an infection and control policy, and staff had received relevant training. The service was mostly clean and odour free, although some bedrooms had unpleasant odours. We identified two people’s bedding was not clean and this had not been noted and addressed by staff. Domestic staff were clear about their roles and demonstrated an understanding of infection prevention and control.

One person who used the service behaved regularly in a way which presented an infection control risk. Although this was documented in their care plan, staffing levels sometimes meant this behaviour could not be safely managed to ensure the associated infection control risks were reduced for this person and others.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We identified a number of concerns relating to the administration of medicines. Some people who used the service had pro re nata (PRN) medicines which are only needed on an occasional basis to address a particular need. We identified 9 people had no PRN protocol in place. This meant staff did not have clear guidance as to when to administer these medicines or for how long before referring the person to a medical professional for further guidance. We reviewed this on our visit on 18 March 2026 and found this had not been addressed and there were a total of 11 people who had no PRN protocol in place.

Although medicines were administered by trained senior staff we identified some had not placed pain relieving transdermal patches in accordance with documented instructions. One patch required the same site not to be used for 14 days but we noted multiple instances where a patch had been placed on the same site too frequently which increased the risk of skin breakdown on that site. Other patches were also placed in the same spot too quickly and medication audits had not identified any issue.

Staff we spoke with demonstrated an understanding of people’s medicines. Staff received training to administer medicines and had their competency to do this checked. However, we identified two staff whose initial medication training was not on record so we could not be assured as to what training they had received or when. One of these staff had made a serious medication error and we identified the medication competency they had undertaken had raised a number of questions about their knowledge and skills, but this had not been followed up. This placed people at increased risk of harm.