Teamcare Limited t/a Highcliffe Residential Home

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

The service was found to be in breach of legal regulation in relation to the safety of people’s care, the safety and cleanliness of premises and equipment, safeguarding and medicines management.

This service scored 34 (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.

The registered manager did not ensure incidents were thoroughly reviewed, investigated or recorded to ensure all necessary actions were taken. For example, a person living at the home had several falls over a short period of time. Incident records had not been fully completed for any of the falls. The person was on blood thinning medication, so falls should have been responded to as a high-risk medical emergency due to the increased risk of internal bleeding, but no medical attention was sought. At the time of our visit, no referral had been made to the falls team to seek advice about the support or equipment needed to manage the higher level of falls.

Risks were not well managed, and incidents were not learnt from. Themes and trends were not adequately reviewed by the provider, registered manager or senior staff, and debriefs were not held with staff to discuss their observations or any learning. Care plans and risk assessments had not been updated to ensure staff were fully aware of these risks and knew the level of support people needed to help prevent further incidents.

There were no records to show incidents were shared with relatives, or reviewed against local authority or CQC guidance, to ensure they were reported in line with duty of candour requirements.

Staff were aware of the required actions following an accident or incident in relation to seeking support from senior staff, assessing people for injuries and logging incidents on the electronic care planning system.

The provider did not always work well with people to establish and maintain safe systems of care or make sure there was continuity of care when people moved between different services.

The registered manager did not always ensure staff had access to the required information about people moving into the service, so risks were fully understood and transitions went smoothly. A person had moved into the home the week before our visit. A relative of theirs worked at the home, but no care plans or risk assessments had been completed about them, and adequate information had not been shared with all staff about the person’s health and care needs or preferred routines. A staff member said, “We didn’t get enough information. I had to ask [relative]. I didn’t have a clue.”

A folder was kept for ease of access for paramedics, which included information about each person in case of hospital admissions. People’s personal details, emergency contacts, risks, allergies, level of cognition and ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) were included.

The provider’s service user guide and website included information and photographs to help people prepare for their move into the home.

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.

The registered manager had an audit tool in place to log and review potential safeguarding concerns, but it was not effective. Several incidents had not been captured or followed up with the required actions or referrals (see the ‘Learning culture’ section of this report for more details). There had been anonymous concerns raised about a member of staff, whilst action had been taken in response to concerns, information was not shared with us as required.

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 MCA. We checked whether the service worked within the principles of the MCA and how DoLS were managed. The registered manager had not identified when people were being deprived of their liberty, and applications had not been made for people living at the service who required a DoLS.

Staff had received training in safeguarding and could tell us the signs of abuse and how they would escalate concerns. Safeguarding information was displayed on the office wall, for ease of access.

Following feedback, the service worked closely with the local authority to review people’s capacity and make DoLS applications for those with restrictions in place. The registered manager was planning to attend advanced safeguarding training to improve their knowledge and skills.

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 and supportive.

People at risk due to specific healthcare needs did not have risk assessments regularly reviewed, and information in care plans about these risks was not robust. For example, those with diabetes did not have information about their specific needs, how staff should monitor blood glucose levels or recognise and respond to signs of hypoglycaemia or hyperglycaemia.

Senior staff did not always update people’s risk assessments or care plans when their needs changed. One person had a moisture lesion, but risk assessments had not been updated for several months, and their care plan made no reference to the skin damage or the support they needed to treat this and prevent further deterioration.

Staff did not always have training in areas to understand how to identify, prevent and respond to risks to the people they supported. There were several gaps to skin integrity, slips, trips and falls, diabetes and Parkinson's training on the training matrix.

People with dementia and/or who could not communicate a need, emotion or distress did not have adequate information in their care plans about strategies staff needed to use. A staff member confirmed they had not received any training about how to prevent or respond to more complex behaviours.

The registered manager had not fully completed or analysed behaviour records to aid learning about what approaches did or did not work for people. One person with dementia would go into other people’s bedrooms. No actions had been put in place to mitigate this risk, other than telling them they could not go into other people’s bedrooms; information they would not have been able to retain.

Whilst people and relatives felt staff helped people to stay safe and confirmed people had the appropriate equipment and support in place, they were placed at greater risk of harm due to the home’s approach to risk management.

Following feedback, the registered manager assured us that care plans and risk assessments were being reviewed, prioritising those people who were at greater risk.

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.

Several environmental concerns were noted during our visit. For example, window restrictors were not in place, and wardrobes had not been secured to the wall, meaning people were at increased risk of falls from height or entrapment. There were people at the home with dementia and/or who lacked capacity to understand risks, but high-risk areas such as the kitchen and sluice room were left unlocked when not in use.

The registered manager had systems in place to schedule external servicing of systems, but these were not effective. We found hoists, fire alarms, fire extinguishers and emergency lighting had not always been serviced in line with the required frequencies; putting staff, people and visitors at increased risk of harm.

The provider had systems to monitor safety at the service, but actions taken in response to concerns identified were not always recorded, so we could not be assured safety had been maintained. When reviewing hot water checks, there were entries which identified taps were running over the maximum recommended temperature. There were no records to evidence action had been taken to reduce the risk of burns and scalds. Internal fire doors were checked quarterly. Several doors had the same concerns recorded for the last 9 to 12 months, with no records repairs had been made.

The provider did not always ensure recommendations from external agencies carrying out safety checks were followed. Works recommended following a fire safety inspection carried out in July 2025 had not been completed at the time of our visits and recommendations from an asbestos survey had not been acted upon.

Staff had training in fire safety, but regular drills were not held to ensure they would be able to respond confidently and efficiently if an emergency evacuation was required. A staff member said, “Drills, they are held mainly when a new carer comes in. Other than that, I am not sure (how often they are).”

Following feedback, servicing and remedial works were scheduled in line with recommendations. Lancashire fire and rescue were asked to undertake a visit to check fire safety measures at the service. Window restrictors were put in place, and wardrobes were secured to the wall.

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.

There were several gaps to the training matrix. For example, end-of life, data protection, equality and diversity and safeguarding children. Most staff had not completed learning disability and autism training, despite this being mandatory for all health and social care staff since 2022.

Staff were recruited safely, with the appropriate pre-employment checks carried out prior to new employees starting work. Staff we spoke to confirmed they received a thorough induction.

Feedback about staffing levels was mostly positive. A relative said, “There are a lot of staff about.” A staff member added, “I do think there’s enough staff. We are lucky to have staff who are very flexible and try to help each other.”

Following feedback, the registered manager advised the service had moved to a new training provider and they were prioritising training to meet the needs of people living at the home.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The registered manager did not ensure there were good standards of food hygiene at the service. We found several concerns to food storage, temperature checks and cleaning records. As a result, we made a referral to the Food Standards Agency, and an inspection was undertaken by them. They reported a lack of labelling and stock rotation, poor standards of cleanliness, a lack of checks and poor food hygiene awareness.

During our visit, we observed several areas which would be difficult to thoroughly clean, such as chipped paintwork and rusted equipment; and found cleaning records were not always robust. There were gaps to daily cleaning records and a lack of recording for deep cleans. Carpet cleaning records were last completed in August 2025.

Whilst housekeeping staff were available daily and feedback from people and their relatives was positive, we received some concerns from staff about cleanliness at the service. One staff member told us, “There is not enough support for housekeepers. They do clean and deep clean, but I don’t think they are given enough time.” Another added, “Cleanliness could be better.”

Following feedback, the registered manager confirmed a deep clean of the kitchen had been carried out and food hygiene concerns were discussed in a team meeting.

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.

People’s administration preferences were not recorded, and there was a lack of information in care plans and risk assessments about their medicines, including high-risk medication such and blood-thinning or time-critical medicines. Details of people’s medical diagnoses or allergies were not included on the electronic medication administration records system (EMARs), to ensure staff had access to the information when administering medicines.

The registered manager did not ensure systems for storing, recording or returning of medication were safe. We found a plastic container filled with loose tablets. The registered manager was not aware of this arrangement, and records did not evidence where the medication had come from or why it was to be returned to the pharmacy. There were gaps to fridge temperature checks, and no system in place to record the temperature of the medication room, meaning people were at risk of being given spoiled or ineffective medicines.

There were no processes in place to ensure medicines were routinely checked or audited, including controlled drugs. The registered manager relied on alerts from the EMARs to identify potential medication errors. They confirmed they had not completed any spot checks or in-depth audits since the system had been introduced.

Staff administering medicines received medication training and had their competencies assessed. People confirmed they received their medication on time and staff were seen to talk to people about the medicines they were being administering.

Following feedback, the registered manager introduced temperature checks in the medication room and assured us auditing of medicines would be improved. Processes for storing medication to be returned to the pharmacy were reviewed.