Arliemoor Care 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 in breach of legal regulations in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, staffing, recruitment and good governance.

This service scored 25 (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. Lessons were not learnt to continually identify and embed good practice.

The service did not demonstrate a strong culture of learning from safety incidents. Managers told us there was no established system for reviewing accidents and incidents to identify themes or trends that could help prevent recurrence. This meant systems and processes had not been sufficiently developed or embedded to ensure safety concerns were consistently identified or that learning was shared.

Although some staff recognised the importance of reporting concerns, systems were inconsistent and did not ensure that lessons were learned. For example, accident and incident analysis was not routinely undertaken; care plans were not reviewed or updated following incidents; and staff had not been supported through reflective practice sessions or debriefs after incidents occurred. This contributed to breaches of regulations relating to safe care and treatment, safeguarding, and good governance.

The provider did not work well with people and health system 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, including when people moved between different services.

Systems to keep people safe were ineffective and placed people at risk of harm. Arrangements to ensure safe transitions into the service were weak, with limited evidence that pre‑admission assessments were consistently completed or used to inform care planning. Risk assessments were poorly completed, which left people exposed to avoidable harm. For example, known risks relating to people’s care and support needs had not been fully assessed or incorporated into individual risk management plans.

Environmental safety arrangements were inconsistent, including fire safety checks and water temperature monitoring. Hazardous chemicals were not safely stored, and people’s medicines were not always stored or managed in a safe manner. This contributed to a breach of regulations relating to safe care and treatment, safeguarding, staffing, and good governance.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always share concerns with the Care Quality Commission in line with their legal responsibilities.

People were not always protected from the risk of abuse. Managers and staff had received safeguarding training and demonstrated a basic understanding of abuse and reporting procedures. One staff member said, “If I witnessed any abuse or had any safeguarding concerns, I would go and speak to [Manager names]. I have information in my folder about whom to contact if I felt nothing was done, and we can always speak to you, too.”

However, this knowledge was not consistently translated into effective safeguarding practice. The provider did not have effective systems and processes in place to prevent abuse or to respond appropriately following incidents. Managers were unable to demonstrate that they had taken timely or effective action to identify triggers, assess risks, or implement control measures following incidents of physical assault. For example, incident records showed that between 14 November 2025 and 30 January 2026, there were three incidents in which people physically assaulted one another.

While these incidents had been reported to the police and the local authority. Incident records and individual care plans did not evidence any updates to reflect identified risks, learning, or preventative strategies. No risk management measures were implemented to reduce the risk of recurrence or to protect people from further harm. In addition, we found that staff had not always taken appropriate action when risks associated with self‑neglect were identified, which further increased the risk of harm to people using the service.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through the Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Where restrictions had been placed on people’s liberty to keep them safe, for example, in relation to where they should live, managers told us they had worked with the local authority to seek lawful authorisation. However, we found that some people were subject to restrictions on their liberty that were not supported by capacity assessments, best‑interests decisions, or lawful authorisation under the Mental Capacity Act 2005.For example, records for one person stated they required supervision when leaving the home. Managers confirmed that the person’s capacity to consent to these arrangements had not been assessed and that a best‑interests decision‑making process had not been followed. As a result, there was no lawful framework in place to support these restrictions.

Restrictive practices were not consistently linked to people’s support plans or risk assessments, and there were no effective systems to monitor or review their use to ensure they were lawful and represented the least restrictive option.

The failure to ensure that staff acted lawfully when depriving people of their liberty, in line with the Mental Capacity Act 2005, contributed to breaches of regulations relating to safeguarding, safe care and treatment and good governance.

People told us they felt safe and were happy living at Arliemoor. One person said. “I do feel safe living here; it’s my home.” Another said, "Yes, it's good here.”

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.

The service's approach to risk management was inconsistent. We found the provider's ongoing failure to take adequate steps to address concerns relating to the management and mitigation of risks meant people continued to be exposed to the risk of avoidable harm. For example, one person had assessed safety needs relating to aggressive, dominating, inappropriate, and disinhibited behaviour. None of these risks had been fully assessed by the provider or included within the person's risk management plan. Staff had not been provided with sufficient guidance on how these known risks should be managed or mitigated. This failure potentially exposed the person, staff and members of the public to a significant risk of avoidable harm.

Where risks had been identified, the provider had failed to take sufficient action to mitigate those risks and keep people safe. For example, incident records for one person indicated at times of increased emotional distress, they may become verbally and physically aggressive towards other people living at the service. We reviewed this person's care records and found there was no assessment of risk in relation to physical aggression or emotional distress. There was limited guidance for staff on how to identify and support this person to manage periods of emotional distress and reduce any associated risks to themselves and others.

People were not always protected from the risk of harm, as staff did not consistently have all the information required to support people safely. For example, one person had known risks relating to the management of their epilepsy. There was no epilepsy care plan or risk assessment in place to support staff in delivering effective epilepsy care. Following the assessment, the provider told us, "All staff have up to date first aid training, which includes epilepsy and understand when to call for emergency assistance.

People's involvement in the development of their care and support varied according to their individual needs and preferences. However, there was limited information to show how staff supported people to be involved in decisions about the development of their care and risk management.

The provider's failure to ensure they were doing all that was reasonably practicable to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm. This contributed to a breach of regulation relating to safe care and treatment, person-centred care and good governance.

The provider did not always detect and control potential risks in the care environment.

The environment was not always safe, well-maintained or treated with the dignity and respect expected of a place that is people’s home. The service had an unpleasant odour, and the whole service required refurbishment, with maintenance issues identified in every room. For example, damp and mould were present in communal areas, and two people’s bedrooms had cracked and damaged windows. Paint was peeling throughout the building, and carpets were worn and visibly dirty. Radiators were uncovered and rusted, and floor and wall tiles were cracked. Some furniture was old, damaged, and dirty and needed to be replaced. In addition, several electrical sockets were overloaded, and hazardous substances were found to be unsecured.

During our tour of the service with the managers, we noted windows throughout the first floor had not been fitted with suitably robust, tamper-proof restrictors to ensure compliance with health and safety legislation.

Some showers were fitted with thermostatic mixing controls that could be easily overridden, allowing hot water temperatures to exceed 44°C. There was no system or guidance in place to mitigate the risk of scalding. Regular testing arrangements were not in place to prevent water from being discharged above 44°C. The failure to identify, assess, and mitigate the risks associated with water being discharged above 44°C placed people at an increased risk of avoidable harm.

External doors were not locked, and had no device to alert staff if someone left the building unattended. This was concerning because the managers told us some of the people living at the service were not able to leave the building without supervision.

Regular checks of the environment and the maintenance of equipment were not consistently carried out. For example, fire safety checks were overdue.

At the time of the assessment, the provider did not have an effective maintenance schedule in place and had not taken action to address environmental safety concerns. Additionally, there was no action plan to address known fire safety issues identified following a visit by Devon and Somerset Fire and Rescue Service in June 2025.

The failure to ensure the service was safe, clean, and properly maintained placed people, staff and others at an increased risk of avoidable harm. This contributed to a breach of regulation relating to safe care and treatment and good governance.

People did not raise any concerns about their living environment.

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.

People were not always protected by safe recruitment practices. We reviewed recruitment records for 3 staff. While some checks had been completed, others were missing. For example, one staff member’s file consisted only of a personal details form and a P60 (end-of-year tax certificate). Managers were unable to locate this person’s recruitment documentation. The failure to establish and operate effective recruitment procedures contributed to a breach of regulation relating to recruitment and good governance.

The provider did not have a dependency tool or formal system in place to determine safe staffing levels. This meant the provider could not demonstrate how staffing arrangements were assessed or adjusted to meet people’s assessed and changing needs. Managers were not able to tell us if the current staffing levels were sufficient to meet people’s assessed needs. One manager said, “There are times when we would like more staff, but we can’t afford it.” Staff did not raise any concerns about staffing levels. One staff member said, “Yeah, staff have been thinning out over the years, but I would say there is enough, and care comes first, and paperwork comes second, so the clients are always the priority, but I guess that is where things need to be done with the paperwork.”

The provider did not have effective systems in place to ensure staff were suitably trained, supervised, and supported to safely meet people’s needs. There was no training matrix available, which meant the provider could not demonstrate oversight of staff training or confirm whether staff competencies were up to date.

While most staff had completed a one‑day mandatory training course covering basic topics in 13 different areas, such as health and safety, fire safety, food hygiene, basic life support and safeguarding. Managers were unable to provide evidence of any training which would underpin this refresher training.

Staff told us they were not receiving regular training, comments included; “We have not had any other training apart from the refresher days – but we have just signed up to some online training”, “We have not had training around mental health awareness, autism, schizophrenia, bipolar or anxiety depression” and “Gosh, trying to think back in more recent years, it has just been that yearly day course refresher training and that has been it.”

Supervision and appraisal systems were poor and ineffective. There was minimal evidence that staff had received regular supervision or annual appraisals. Where supervision had occurred, it was not used effectively to assess staff competence, promote reflective practice, or identify and address performance concerns. In addition, there was no evidence that staff participated in debriefing or reflective practice sessions following incidents, which limited opportunities for learning, improvement, and professional development.

While all staff told us they felt supported by both managers. Staff consistently told us they did not receive regular supervision. Comments included: “In the last 12 months, I could not tell you, I think I can only think of 1 supervision, and that was a few weeks ago, but I can’t remember, the last one could have been in 2024.” “I think I had 1 supervision the other day, but I could not tell you when the last one was,” and “We have not had supervision for a long time, but I did have one on Monday since you guys have been, and I have just had an appraisal.”

The failure to recruit and deploy sufficient numbers of skilled staff to meet people's assessed needs, to ensure staff received the support, training, and professional development necessary for them to carry out their roles and responsibilities, placed people and staff at an increased risk of avoidable harm. This contributed to a breach of regulation in relation to recruitment, staffing, safe care and treatment, and good governance.

The provider did not consistently assess or manage the risk of infection.

The service had an unpleasant odour, was not clean, and was poorly maintained. This placed people at risk of infection and compromised their dignity. We identified widespread issues with cleanliness across the environment. Most surfaces, including walls, showed visible grime and dirt, and mould was present in several areas.

Bathrooms were visibly dirty. Some furniture throughout the service was unclean, and in some areas was covered with dog blankets and dog hair. This presented clear infection prevention and control risks and did not demonstrate respect for the environment as people’s home. A staff member said, “I was cleaning all morning before the infection control people came and I said to [Manager’s name] I don’t think it is enough because it still doesn’t look great”

There was no effective system in place to manage laundry safely. Poor laundry practices increased the risk of cross‑contamination and did not align with infection prevention and control requirements.

Cleaning schedules were unclear, and cleaning records were missing or incomplete. We reviewed a monthly deep‑clean audit dated November; however, the year was not recorded, and the documentation did not clearly identify which areas had been audited or whether any actions had been taken. As a result, the provider could not demonstrate effective oversight or assurance that cleaning standards were monitored or maintained.

Staff told us that personal protective equipment (PPE) was readily available; however, we found PPE was stored in a manner that did not protect it from cross‑contamination, presenting an infection risk.

Poor infection prevention and control practices and ineffective governance systems placed people, staff, and others at risk of harm. These failures contributed to breaches of regulations relating to safe care and treatment, dignity and good governance.

People did not raise any concerns about their living environment.

The provider did not have safe or effective systems in place for the storage, management, and administration of people’s medicines.

People’s medicines were not always managed or stored safely. For example, the cabinet used to store people’s medicines was not suitable for its intended purpose. It did not meet NICE guidance or comply with the requirements of the Misuse of Drugs Act 1971 or the Misuse of Drugs Regulations 2001. Although the cabinet was locked, it could still be accessed, which meant medicines were not securely stored. This meant people’s medicines were accessible to unauthorised staff and others.

Medicines were stored inappropriately. For example, one person’s inhaler was kept in an open bowl in the kitchen next to defrosting shellfish, presenting a clear risk of contamination. Medication administration records (MAR charts) were stored on the kitchen work surface, where people could easily access them, compromising confidentiality and safety.

We found a box of medicines awaiting return stored in a chemical cupboard. Staff were unable to locate the medicines return book, meaning the provider could not demonstrate safe oversight or accountability for medicines awaiting disposal. In addition, eye drops that required disposal were found left on a surface, indicating poor medicine disposal practices.

One person was prescribed a high‑risk medication for which missed doses of more than 48 hours require re‑titration to avoid serious side effects. This information did not form part of the person’s care plan, and there was no medication‑specific risk assessment in place to guide staff on the actions required to mitigate these risks.

This meant staff were not provided with the essential information needed to support the person to manage the risks associated with their medicines safely.

Another person had been prescribed diazepam on a ‘when required’ (PRN) basis; however, there was no PRN protocol in place to guide staff on its safe use. Records showed the medicine was administered every day, which did not reflect PRN use and raised concerns about inappropriate administration and monitoring.

Staff confirmed they had received training in the safe administration of medicines. However, the provider had no system in place to assess staff’s competence.

Managers were unable to provide evidence that medicines audits were being completed or that the provider had identified the concerns we found. This contributed to a breach of regulation relating to safe care and treatment, person-centred care, staffing and good governance.

People did not raise any concerns regarding the safe administration of their medicines. One person. “The staff manage my medication.”