Prideaux House

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 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 people’s safe care and treatment.

This service scored 53 (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. Accidents and incidents were not consistently reported and some reports lacked detail. We found one record containing photographs of an injury but no accompanying accident report. Another recorded pressure wounds acquired during a recent hospital stay but there was no follow up or records to show how this had then been managed. Another report recorded a head injury but lacked detail about actions taken. We saw 2 examples of where people had lost significant weight during a short period of time and although recorded, no action had taken place. Reviews had not identified these trends with care plans being marked as ‘medium to low risk.’ All of these were brought to the attention of the registered manager who agreed to review the incidents and acknowledged improvements were needed. There were some records showing time and space analysis of falls, a map showing location, date and time. However, this document was quite old and not relevant to recent incidents and there was no indication of follow up or details of lessons learned from repeat incidents. Staff told us that they were updated during handover meetings between shifts with anything significant that had occurred during the previous shift but that they were not told about any longer-term themes or trends. Staff were aware of the processes to follow when managing and then reporting accidents but these were not always followed. Relatives told us they were kept informed if anything happened involving their loved ones.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People’s support when arriving at the service from hospital was not always consistent, with some people being returned with pressure sores and others having lost weight since being away from the service. Although these issues were noted, there was no follow up action and no contact made with the local authority or CQC. Onward transitions from the service were however managed well. The registered manager was aware of the importance of people being able to remain at the service for as long as safely possible and that moving people was disruptive and upsetting for some people and their relatives. However, if people’s needs could not be met then transitions to other services for example, nursing homes and hospices, was arranged appropriately. The registered manager told us, “We do what we can in house first. We make various referrals to (for example) the mental health team, district nurse and speech and language therapists (SALT) and will only move people when it is in their best interests.” Professionals confirmed smooth onward transitions with one telling us, “They generally facilitate prompt and appropriate support when residents transition between care settings or require changes in medication.”

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 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 always share concerns quickly and appropriately. Safeguarding incidents were not always reported in a timely way and some incidents had not been identified by the registered manager as safeguarding incidents. Between September 2025 and January 2026, 6 safeguarding incidents occurred that were not raised by the registered manager but have now been identified and reported by the operations manager. These included skin tears and a hot drink being spilt over a person. The registered manager told us they were confident in identifying safeguarding concerns and that they knew the process of how to report however, this had not occurred in these cases. Staff had received safeguarding training and were able to describe to us events that they would report and escalate to managers. A staff member said, “I would tell a senior or the manager if I was not happy with something. There was a whistleblowing policy in place but most staff were not aware of this or did not know how to use the process. Whistleblowing provides legal protection for staff raising concerns and protects anonymity. Mental capacity assessments were in place for people needing support with some decision making. Although in most cases assessments were decision specific, we found little evidence of relatives or other professionals being involved in best interest decisions. Best interest meetings or discussions are between the person, their relatives or advocates, staff and other professionals, to determine the least restrictive and most appropriate options for people who need support in making certain decisions. Deprivation of Liberty Safeguards (DoLS) had been applied for and were in place for people where required. DoLS provide a legal framework to protect people who lack mental capacity who live in a care environment.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff did not consistently respond to potential risk situations. Several people lived with the risk of developing pressure sores but staff were not able to tell us how they managed people at risk of developing sores. Similarly with catheter care, although a risk assessment for catheter care was in place and it was noted that there was a high risk of infection if catheters were not cleaned and maintained daily. However, staff had not received training in catheter care. Staff response to an incident where a person was struggling to eat as the size of the food was too large for them to manage, was poor. The kitchen was approached for an alternative and nothing suitable was available. Staff dealing with the incident did not appear to understand the severity of the issue and that the food offered, presented a choking risk. Another situation involved a person returning from hospital with unexplained bruising and pressure sores. Body maps were provided by the hospital but no apparent action had then been taken by the service. All of these concerns were noted by the area manager who had started an action plan for immediate improvements in all of these areas.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service was well maintained. A dedicated member of maintenance staff addresses issues raised in a day book by staff and carried out decorating tasks and general maintenance around the service. Maintenance certificates were in date for electrical appliances, gas and legionella. A fire risk assessment was in place and regular testing of equipment including fire alarms, were carried out. Personal emergency evacuation plans (PEEPs) were in place and up to date and were kept in care plans but with a copy easily accessible in the event of an emergency. Temperature checks had been carried out regularly on hot food served to people and all of the electrical equipment used in the kitchen.

The provider did not always make sure there were enough fully qualified and skilled staff on duty. 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. Staff supervision meetings were inconsistent and although staff training was largely up to date, an important element of training was missing. Training was not provided in catheter care despite staff being expected to support people who needed catheters. Service policy at the home stipulated that staff should receive supervision meetings, one to one time with their line manager, every 6 months. This was not happening with some staff not having these meetings for over 9 months. There was a high turnover of staff at the service with 15 members of staff having left during the past 12 months. However, staff numbers overall were maintained and there was enough staff on duty for each shift. There was some dependency on agency staff but every effort was made to use the same staff members for consistency. Staff had been recruited safely. Staff files contained the required documents and checks for example, references, photographic identification and Disclosure and Barring Service (DBS) records. Disclosure and Barring Service checks support managers to make safe recruitment decisions.

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. The service was clean and two domestic staff were employed to cover 7 days a week. Staff had received training in infection prevention and control and the use of personal protective equipment (PPE). There were well stocked PPE stations throughout the service. A member of staff told us, “We have enough and uniform, not a problem and can dispose of PPE and clothes to wash.” A relative said, “It’s clean, absolutely perfect. Carpets look like they have just been hoovered, her room is nice and clean and there are antiseptic wipes everywhere for staff and people to use.” Bedrooms were not en suite but each room had a commode. These were checked and cleaned regularly by staff.

The provider did not always make sure that medicines and treatment management were safe and met people’s needs. Medicine management was generally completed well although there were some shortfalls. Some PRN, as and when required, medicine protocols were generic. Some medicine number counts on medicine administration records (MAR) had been missed and there were some out of date items in first aid boxes. However, medicines were administered safely and were stored and disposed of appropriately. Dedicated members of staff carried out the medicine round and wore a specific tabard to make sure they were not distracted or taken away form that role. Comments from relatives included, “They support with medicines. They need to make sure they swallow safely and “They have regular reviews involving their GP.” A member of staff said, “Medicines are managed well here. Every person has their own box. Some staff need reminding about signing MAR charts but otherwise all okay.” The registered manager told us of a positive working relationship with the local pharmacy and GP surgery and that medicine reviews were regularly carried out.