Duke Street Bungalows

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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 always ensure there was a proactive and positive learning culture.

Following an incident that had occurred at the home in April 2026, the registered manager had identified learning from incidents was an area that they could improve on. They told us and we saw they had added this as a standard agenda item in staff meetings so this could regularly be discussed and embedded throughout the home.

There was a process in place to ensure lessons were learnt and when incidents or safeguarding’s had occurred, investigations took place and any areas of learning were identified and actioned. However, we could not be assured these systems were fully effective. An incident had recently occurred that had resulted in an investigation and minutes of a staff meeting in May 2026 recorded ‘The investigation that has been completed has highlighted that our record keeping is not as stringent as it should be’. This showed the outcome of the investigation was shared with staff. However, the investigation had failed to identify there were no care plans in place for a change in a person’s mobility following this incident. We could therefore not be assured the learning they had identified was always effective or reflected into people’s care.

Staff told us information was shared with them from the registered manager, and they felt involved with all aspects of the home, including when learning lessons had been discussed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Most people living at the home had lived there for a long time. However, the registered manager confirmed there were processes in place to ensure people’s needs were assessed before they moved in. Relatives confirmed they had been part of these assessments. Staff told us they were aware of people’s assessed needs and used this information to ensure they delivered safe care.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately.

People and relatives raised no concerns about safety. One person told us, “I feel safe and looked after well”. A relative said, “She's definitely, definitely safe. She's very happy there”.

There were systems in place to ensure safeguarding concerns were identified, reviewed and investigated. Staff had received training and were able to tell us the action they would take if they were concerned. They felt confident to raise concerns.

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 checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that when needed, DoLS were in place for people.

The provider did not always work well with people to understand and manage risks.

People had care plans and risk assessments in place which contained information about their needs. However, 1 person had experienced an injury which had impacted on their mobility, there was no care plan in place for the changes that had occurred to this person’s mobility due to this. At the time of the incident a risk assessment had been implemented, however this had not been updated and did not reflect how the person currently mobilised. This placed this person at risk of receiving unsafe care if they needed care and support from a new or temporary member of staff. Staff we spoke with were however aware of how this person should mobilise and we saw they used the equipment they needed to keep them safe.

Another person had a health condition which staff had identified had changed. The care plan did not reflect these changes and the measures that had been implemented to manage the change of this condition. Although staff we spoke with were aware of these changes, this placed this person at risk of not consistently receiving the care and support they may need.

After our site visit the registered manager confirmed these plans were now in place and up to date, we will review this as part of our next inspection.

We viewed an Epilepsy support plan for 1 person that had been completed by a health professional, this identified they needed a check every half an hour throughout the night. Records showed and the registered manager confirmed they were receiving an hourly check. The audits of care plans and records completed had not identified this discrepancy, and that checks were not being delivered in line with professional advice. After the inspection the registered manager told us they had contacted the health professional and confirmed the checks should be completed each hour. We will review this as part of our next inspection.

Despite this, people and relatives were happy with how their risks were managed and raised no concerns. One person told us, “Staff help to look after me and I am safe in bed and in the shower”. A relative told us, “[Name of person] is in a wheelchair and they use a hoist. It's always 2 staff and there's no cause for concern”.

Other care plans and risk assessments in place were individual, detailed and regularly reviewed when needed and when changes occurred. They identified people’s individual risks and the levels of support they may need. For example, people had detailed care plans in place when they were at risk of choking and required a specialist diet.

The provider detected and controlled potential risks in the care environment.

People looked happy and comfortable in their environment and raised no concerns to us. People had access to equipment they needed to keep them safe, including equipment to mobilise. The environment had been adapted and decorated to meet people’s individual needs and people showed us these areas. This included in people’s bedrooms where they had decorated their rooms with things that were important to them such as photographs of family members, religious items and equipment for hobbies they enjoyed participating in. Specialist equipment was available so people could safely use the bath and shower and people had access to outdoor spaces.

Where needed, any risks to the environment or premises had been considered and assessed. For example, a fire risk assessment was in place that was regularly updated and reviewed. There were processes in place to ensure any risks were identified so that appropriate action could be taken.

The provider had systems in place to ensure there were enough staff available to support people.

People and relatives confirmed this. One relative commented, “There's always enough staff”. We saw there were enough staff available to support people in line with their assessed needs and staffing they had been allocated. In addition, people were allocated additional hours to participate in activities, including visits to the local park, shops, day trips and pub visits.

Relatives felt staff were well trained, 1 relative told us, “So far, I would say they are well trained”. Staff told us and records confirmed staff had received training. This included mandatory training and training that was specific to people’s individual needs, such as learning disability and autism training. We reviewed the training matrix, and this confirmed staff training was up to date.

Staff had received the relevant pre-employment checks before they could start working in the home to ensure they were safe to do so.

The provider assessed and managed the risk of infection.

People and relatives were happy with the cleanliness of the home. One person said, “I like my room it’s clean and I can help clean”. A relative told us, “They [staff] wear Personal Protective Equipment”.

We saw the home was clean. Staff told us and records confirmed they had received training. There was enough Personal Protective Equipment (PPE) available for staff, and we saw this was used throughout our inspection. There were processes in place to monitor IPC to ensure concerns were identified so that appropriate action could be taken.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People and relatives were happy with how they received their medicines. One person told us, “I have my tablets from staff”. A relative said, “They deal with their medicines. I am kept informed of any changes”.

We saw medicines were stored safely. When people had ‘as required’ medicines there was guidance in place for staff to follow. Staff administering medicines had received training and their competency was checked to ensure they were safe to administer these to people.