Quarry Mount

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 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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff reviewed accidents and incidents, and there had been some actions taken and lessons learned from these. However, preventative measures and actions were not always recorded or effective.
For example, there were four falls recorded in June with no recorded actions.

Despite this, we saw evidence of some learning from other incidents, such as discussions in team meetings with staff. Following the inspection, leaders were open and responsive to feedback which demonstrated commitment to learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People had documents in place to support safe admissions to hospital, which contained key information about their needs. This enabled hospital staff to know how to support people.

The provider did not always work with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff did not always concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

All people’s bedroom doors locked automatically when they closed, with keys on chains outside the rooms. This had been implemented following incidents where people had entered the wrong bedrooms. This meant people were not always able to access their own rooms if they were not able to use the key independently and had to rely on staff support. Records demonstrated incidents where this had resulted in harm and distress to people. This was a blanket approach and the least restrictive arrangement for each person had not been considered impacting on their freedom within the service. Leaders told us they were reviewing people’s access to their bedrooms. The manager said, “We are reviewing the arrangements individually, taking account of each person's wishes, capacity, consent, risks, privacy and independence.”

However, people told us they felt safe. Staff had a good understanding of safeguarding procedures. Incidents were referred to the local authority safeguarding team and the CQC where appropriate.

Leaders had a system to monitor Deprivation of Liberty Safeguards and these were appropriately in place for those who required them.

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.

People’s care plans did not always contain clear guidance. For example, one person who was on a modified diet, had 3 different food textures listed within their care plan. This meant there was a risk of staff following the incorrect information. However, we saw staff supported the person with the correct food texture during the site visits and staff knew which was the correct consistency level.

Risks relating to falls were not adequately assessed. People had falls risk assessments in place where required, however these did not always contain all relevant details. For example, one person was on blood thinners. The person’s falls risk assessment did not make reference to the fact the person was on blood thinners so staff may not have known how to respond effectively to falls for this person. However, risk assessments were reviewed and updated after people fell.

Another person’s care plan stated they required repositioning every 2-4 hours, however care records demonstrated this person was being repositioned less frequently. The manager told us this person did not require repositioning due to having equipment which repositions the person automatically, and they would review the person’s care plan to ensure it was an accurate reflection of support required.

However, other risks to people were considered. Staff supported people to positive risk take, for example one person was supported to attend their own medical appointments, and another person was supported to meet their friend without staff support

The provider did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.
The provider had not considered the risks relating to freestanding wardrobes, which put people at risk of injury from falling on people. We raised this with leaders who told us these had now all been attached to the walls.

People’s bedrooms automatically locked and a key was required to access these. This could impede a fire evacuation at put people at risk of harm. We raised this with the local fire service.

Oxygen was not stored safely at the time of the inspection, however leaders removed this once identified. Health and safety audits took place but had not identified these shortfalls.
However, staff were trained in fire safety. All health and safety certificates were in place, such as gas safety and electrical safety checks.

The provider did not always make sure there were enough qualified, skilled and experienced staff. However, they made sure staff received effective support, supervision and development.

We observed people sat around for long periods of time with very little engagement from care staff and staff did not always meet people’s needs in a timely way, despite their best efforts. People generally told us they felt staffing levels were not sufficient. Comments included, “There’s not enough staff, there could definitely be more” and “They are definitely understaffed”. Staff also commented they felt more staff were needed at busy times throughout the day. Comments from staff included, “Our residents have increased, we need some more of staff” and “Some days it’s okay, some days we feel we are struggling.” We raised this with leaders who told us they would review the tool they used to calculate staffing levels.

During the inspection, we observed one staff member using incorrect moving and handling techniques to support a person to stand. This placed the person at risk of injury. We also received some concerns from a relative in relation to catheter care. We checked training records and staff had not been trained to an appropriate level in catheter care, despite supporting a person with a catheter. We raised this with leaders for them to address.

Staff told us they received support and supervision. We saw evidence of regular supervisions held for staff. Staff had received training relevant to their role. Staff had been recruited safely.

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.

People were not protected from the risk of legionella. Staff were not regularly completing cold water outlet testing, which protects people from legionella. Additionally, there had been a legionella risk assessment at the service, which was completed in February 2026, but there were actions from this which had not been completed at the time of inspection. We raised this with leaders who addressed this during the inspection, and we received confirmation that the remedial works were completed following our visit.

However, the home was clean. Relatives commented, “There always seems to be someone cleaning” and “[Domestic staff] deserves a medal.” Staff completed regular audits in relation to infection control.

The provider did not always make sure that medicines and treatments were safe.

We saw medicine storage temperatures exceeded the maximum recommended safe temperature for a period of 5 days; however, staff had not acted on this such as contacting a pharmacist for advice. This meant the medicines may have lost their effectiveness. One person’s medicine needed to be administered with food, however records showed this had not administered with food. This meant the medicine may not have been as effective.

However, there were no gaps in MAR charts. People had detailed protocols in place for ‘when required’ medicines such as pain relief. Medicines were stored securely.