Thames 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 inspection we rated this key question good. At this inspection 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 provider was in breach of regulations relating to safe and effective staffing as leaders had not ensured staff had completed clinical key skills training which was highly relevant within their roles.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learned to identify and embed good practice; however, this was not consistent.

The provider had a lesson’s learned file, which contained 2 different documents; organisational lessons learned, and internal lessons learned. Organisation lessons learned had been used to review more serious incidents, to analyse what had happened, where any failures had occurred and what lessons could be learned from this. The lessons learned process had identified care plans needed to be clearer and more detailed, and better monitoring and record keeping maintained. The organisational lessons learned documentation included an action section. This listed what actions had been generated from the process, who was responsible for completing and in what timeframe. However, there was no section for recording updates or reports of progress to confirm the action had been completed. It was not clear where this information was documented.

The internal lessons learned documents were a list of expectations which staff needed to adhere to, rather than an analysis of issues and consideration of what lessons could be taken from this. For example, an internal lessons learned document covered issues with personal care records not being completed fully and activity logs not being completed fully, thoroughly and consistently. Although identified in February 2025, all these issues had not been resolved and were noted during this inspection.

The provider used an electronic system (RADAR) for recording accidents, incidents or information of concern. Following any accident, incident or other reportable event, staff documented what had happened and initial actions taken. The manager reviewed this initial information and applied a risk score. The level of identified risk determined what actions and/or what tasks were automatically generated by the system and assigned to staff members for completion. The provider was able to view the system in real time, which allowed for ongoing monitoring of progress and helped improve oversight.

We reviewed the last 3 complaints received and what actions had been taken. The leads of the service had escalated concerns which required further input and were swift in their actions in resolving or investigating them.

The service user guide provided clear guidance of how people using the service could escalate their concerns.

Staff had a clear understanding of what would constitute an incident and knew how to report them. Staff felt there was a good culture regarding safety and learning and felt lessons learned from safety incidents or complaints were shared in appropriate forums such as handover meetings.

The provider made sure there was continuity of care, including when people moved between different services.

Staff followed the providers’ policy regarding people enquiring about and/or being referred to the service.

They made sure there was continuity of care, including when people moved between services. Staff completed pre–admission assessments with people before they moved into the service to ensure their needs could be met. We saw evidence of effective communication between staff and external professionals when people were moving into the service which ensured a smooth transition.

People had an emergency admission pack, which provided crucial information about the person to the service they had been referred to.

The provider worked with local discharge teams and the local authority which ensured people were safely placed at the service.

Most staff felt they were involved in decisions regarding a new person joining the service and felt they had enough information provided to them to ensure they were cared for according to their specific needs.

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.

Staff made safeguarding referrals when required and leaders identified actions following safeguarding concerns being investigated. The provider ensured external bodies such as the CQC were informed of any safeguarding concerns in a timely manner.

Staff had completed training for safeguarding adults and safeguarding children and had high rates of compliance. Nurses and managers had level 3 safeguarding training, and these members of staff were all up to date with their training.

Staff had a good understanding of safeguarding, including Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) and could explain how they took appropriate action. Staff reported people as being safe from abuse.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Safety checks were completed with certification in place, to confirm utilities and equipment were safe to use; detailed records were kept of all equipment certificates and utilities supplies. Portable appliance testing was up to date and equipment was serviced as required. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Regular fire safety checks and fire drills were completed; an external fire risk assessment had been completed in July 2024 and any remedial actions identified had been completed the following month. The manager and provider carried out audits of the environment and safety checks in place; there were effective arrangements to monitor the safety and upkeep of the premises.

Maintenance staff had a good knowledge of recommended safety measures and checks, and quarterly health and safety meetings were held. Any environmental issues were discussed at daily shift handover meetings and other staff meetings held each day. Hazardous substances were stored securely, window restrictors were in place, and flooring was well maintained and free from trip hazards. Health and safety checks, including hot water temperatures, bed rails, mattresses checks, equipment checks, environmental checks, and legionella checks and flushes had been completed and documented.

The environment had been specially designed to meet people’s needs and decoration was of good quality. Corridors were wide and free from clutter and bedrooms had ample space to move around. People had emergency evacuation plans in place; during the inspection we were told these were being transferred from paper-based records onto the electronic care planning system.

People’s rooms were personalised and decorated to their own choice. The service user guide contained information on how staff could help people to decorate their own room and stated there were no limitations to what people could have in their bedroom. There was a multi-sensory room in place on ground floor, which people could use when required. There was signage around the service to help people orientate. Staff hand hygiene was monitored, and staff had completed appropriate health and safety training, including moving and handling and fire safety.

There was a secure, enclosed, and well-landscaped garden area, and we saw many people enjoying using this space throughout this inspection.

Staff did not raise any concerns regarding the environment or equipment within the service. They confirmed that fire evacuation drills were completed regularly.

Most relatives were happy with the environment and equipment used, however a relative had mentioned a piece of equipment which [person] relied on had broken, and the provider had not replaced it for several months.

The provider did not always ensure staff were suitably skilled and trained in their roles to meet the needs of the people they supported. Staff training compliance in a range of clinical skills was poor. However, the provider made sure there were enough staff on shifts and staff received regular supervision.

Staff received clinical skills training which included modules specific to the people who were being supported. Training included stroke awareness, Huntington’s disease and dementia e-learning. The overall compliance rate for clinical skills training was 63%. Some modules had good compliance including dysphagia training but other modules such as pressure ulcer prevention (10% compliance), tissue viability training (25% compliance) and respiratory and tracheostomy training (21% compliance) needed improvement. Providers should ensure staff are supported to complete any additional training identified as necessary to meet people’s assessed needs.

The average staff compliance rate regarding mandatory training was 89%. Most of the mandatory modules were above 90% compliance, however improvement was required in moving and handling level 2 (clinical) which compliance was 80%, first aid resuscitation level 2 which compliance was 72% and positive behaviour support level 1 refresher training which compliance was 45%.

All staff we spoke with and those we received questionnaire responses from, felt the training they had received was adequate in assisting them to complete their role safely. However, some relatives commented negatively on staff; a relative told us, “They [staff] are trained but some of the staff are appalling. I was there and [person] was crying, and 2 members of staff were just sat in chairs.”

The staff rotas between 24 February 2025 and the 31 March 2025 showed there were adequate numbers of nursing staff and healthcare workers on both the day and night shifts. However, the rotas did show a reliance on bank staff and agency staff, especially at weekends.

During our inspection, we saw that there was a vacancy for a unit manager, however, a new staff member had been recruited to this post and was due to start shortly. Staff we spoke with, or received questionnaire responses from, told us there were always enough staff; a staff member said, “I am amazed by the number of staff on duty every day.” However, peoples’ relatives did not always agree; a relative said “There’s a massive turnover of staff; they don’t stay. There aren’t enough staff. He [manager] says there’s enough staff, but there aren’t.”

Staff received an induction when they first stared working at the service and additional training appropriate and relevant to their role. A staff member commented, [via written questionnaire] ‘I went through the induction procedure which has provided me with a good starting point.’

Staff received regular supervision from their seniors. Some of the supervisions documented were not personalised with most of the text being copied and pasted from 1 document to another. We raised this with leaders who were aware and were addressing it with the individual member of staff concerned.

Software was in place to ensure refresher training was up to date. The staff training lead told us any staff new to care were required to complete the Care Certificate, which is a set of 15 standards for health and social care support workers, designed to ensure they have the necessary skills and knowledge to provide safe and compassionate care.

Leaders recruited staff safely, with all necessary checks and documentation in place. Application forms were fully completed, and at least 2 references were obtained prior to a starting work. Interview questions and answers forms were kept. UK disclosure and barring service (DBS) checks were completed to ensure staff were of suitable character to work with vulnerable adults. Nurse revalidation records were completed and up to date.

There was a ‘staff champion’ notice board on display with a picture of the relevant staff member and a short description of why they did the champions role. There were champions for dignity, equality and diversity, mental health and oral care.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic, and there were no offensive odours. We did identify some rips to some of the fabric on the chairs in the living areas which posed an infection risk, but we were assured by leaders and the maintenance manager these were due to be replaced.

Daily and weekly cleaning schedules were signed and dated to show they had been completed. Managers audited the cleanliness of the service to ensure standards were maintained, IPC audits from the last 3 months showed compliance with standards with an average rating of 99%.

There was an up-to-date policy on the control of infection, (IPC) which staff could refer to if needed. Staff were trained in IPC and had access to personal protective equipment (PPE). We observed staff were bare below the elbow and wore PPE, when applicable, to help prevent the spread of infection.

There were hand washing stations throughout the service and IPC signage all around the building. Staff used appropriate cleaning products which were stored safely, and waste materials were disposed of properly. Enough staff were employed to keep the premises clean. Staff told us they did not have concerns regarding IPC within the service. A staff member told us, “We follow the rules, and everything is done by the book, for example, how people’s clothing is dealt with.”

The provider had systems in place to make sure medicines and treatments were safe and met people’s needs, capacities and preferences. We found some concerns with the recording of some health observations, as it was not always clear that these had been completed. Therefore, there was a risk that staff might not be able to identify or take action when a person’s health had deteriorated; the management team acted on this when this was discussed. The service should seek further pharmacy guidance on how medicines should be administered when crushed to ensure this is done in a safe manner.