121 Watleys End Road

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.

This service scored 59 (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 learnt to continually identify and embed good practice.

The service had effective systems to capture incidents, accidents and complaints. This included what the concerns were, what action had been taken to minimise further risks and any learning.

Lessons were learnt to identify and embed good practice. The registered manager held regular meetings, where staff could share safety concerns and good practice. Daily handovers between shifts kept staff updated about any changes or concerns they needed to be aware of.

Staff shared with us learning about some recent medication errors and what actions they were doing to minimise the risks to people. Staff said additional training was provided on the system and improvements had been made to the WIFI to enable them to use the electronic system. Where a person’s medication was complex, 2 staff were involved in the dispensing process and checking the medication to reduce further risk to the person.

There was evidence of openness and transparency, in line with duty of candour requirements. The registered manager was clear about their responsibilities for reporting to the CQC and the regulatory requirements of their role. Relatives confirmed they were kept informed of any incidents, accidents or safeguarding concerns.

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’s needs were assessed before moving to the home. A relative commended the service on the support that was in place to help their relative settle into the home. Nursing staff had visited and spent time getting to know the person at their previous care home. The 2 nurses then ensured they were on duty for a period of 2 weeks supporting the staff team to get to know the person enabling them to successfully settle in their new home.

The service used healthcare passports to support people when they were admitted to hospital or moved from one service to another to ensure continuity of care. This contained important information enabling health professionals to get to know people. This enabled them to make adjustments as needed, such as how a person communicated and the support they needed to make decisions.

People were supported when they went into hospital due to the complexities of people’s healthcare needs and to support with communication.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The registered manager had appropriately raised safeguarding concerns. This included sharing information with the local authority and the Care Quality Commission (CQC). The level of information shared with other agencies had been appropriate and sufficient to keep people safe. As a result of the safeguarding concerns and subsequent investigations, changes were made to people's care arrangements when required to keep them safe and help prevent recurrence.

Staff confirmed they knew what to do in the event of an allegation of abuse being made. Staff had completed safeguard training. There were policies and procedures to guide the staff on what to do if an allegation of abuse were made and how staff could raise concerns using the whistle blowing policy.

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 appropriate assessments and applications had been made. One person did not have a care plan around their DoLS and mental capacity. This was addressed during the assessment.

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 included risk assessments to guide staff to support people safely covering areas such as moving and handling, support with eating and drinking and with their health conditions.

Some risk assessments were detailed, whereas others needed updating or had not been fully completed. For example,1 person was no longer eating a pureed diet, but this was still embedded into their care plan and risk assessment this potentially put the person at the risk of choking. One person’s care plan made reference to a lift but there was no lift in 121 Watleys End Road. This care plan had not been fully updated when they had moved to the service from another of the provider’s services.

Another person’s risk assessment in respect of supporting them with epilepsy had not been updated to reflect that the rescue medication should be administered after 2 minutes and not 5 minutes as detailed in the care plan. Action was taken when we raised these with the provider. No harm had been caused to people.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

A fire risk assessment had been completed by an external contractor in May 2025. The provider had completed some of the actions that had been identified such as replacing fire doors and completing some remedial work in the attic space. The registered manager told us they were planning to replace the fire panel as part of the action plan. Most staff had received fire training every 2 years. Fire drills had not been completed with all staff including night staff. The last recorded fire drill was April 2025 with only 14 staff taking part. This potentially put people at risk in the event of a fire as staff may not be confident in the evacuation process.

There was a programme of ongoing maintenance, refurbishment and decoration. Some areas of the home were being redecorated such as the kitchen and a bedroom during the assessment. One person was moving to a larger room, which had previously been the office. Staff had strongly advocated for this as it would be beneficial to the person offering them a larger room.

Some areas of the home were cluttered such as the small lounge area. The conservatory was temporarily being used as the office. The provider had identified that some areas of the home would benefit from being made more homely and was addressing this.

The service had effective systems to ensure the home was safe. This included checks on equipment, legionella checks, fire and gas appliances. Adaptations such as key codes on doors, restrictors on windows and covers on radiators all helped to keep people safe.

The home was wheelchair friendly with wide corridors and ceiling hoists were available in people’s bedrooms, bathrooms and lounge area. Staff felt confident to report any concerns about the environment and equipment. Staff completed daily visual checks on specialist equipment such as slings and hoists. However, monthly checks on people’s moving and handling equipment was not being recorded in accordance with the expectations of the provider.

The provider did not always make sure there were enough qualified, skilled and experienced staff. 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.

There were sufficient staff to keep people safe. This included nurses, care staff, housekeeping and catering staff. Daycare staff supported people with activities alongside the care staff. We observed staff were available to support people when they needed support.

We received mixed feedback from staff about staffing levels. Staff told us the home was very busy and due to the complexities of the people they supported often administrative tasks were not completed or delayed. Where agency staff were used they said this had impacted on the care and support, but people remained safe.

Recruitment of staff was ongoing. The registered manager said the home was nearly fully staffed with ongoing recruitment taking place. This had meant that agency usage had reduced. The provider told us they continually reviewed staffing to ensure it was safe.

People were supported by staff who had an induction that included shadowing more experienced staff, ongoing training and formal competency checks. However, agency staff had not always completed the in-house induction. Records were either incomplete or not available.

Staff new to care completed the Care Certificate as part of their induction. Staff had completed the Oliver McGowan Training. This is specific training to support autistic people. Staff completed mandatory training in a variety of topics. When we checked compliance, there were a small number of staff who were not fully compliant and had not completed their required training. Two staff had not completed first aid training although they had worked at the service for a number of years. Some staff were waiting for face-to-face training. The registered manager was aware there was outstanding training and this was discussed with staff during team meetings.

Staff told us they were not receiving regular supervisions in line with the provider’s policy. When we reviewed the supervision matrix there were significant gaps. The registered manager told us they were aware this was an area that needed improvement. Staff said often supervisions were arranged but cancelled due to other priorities within the home.

The provider safely recruited staff, and relevant checks were carried out before staff started working at the service. This included criminal record and employment checks to confirm staff were suitable to care for vulnerable people.

The provider did not always assess or manage the risk of infection. Two members of staff were observed not wearing their masks appropriately as these were under their chin and not covering their mouth. The service had an outbreak of the winter flu virus the week before the assessment. Staff described how they had minimised this by supporting people in their bedrooms during the outbreak and following the guidance from public health.

A clinical audit was completed by the provider’s quality assurance team in the summer of 2025. The service was advised to complete an infection control audit, and this was to be completed annually. This had not been completed since 2022. We saw that there were a number of bins that were not pedal action, which potentially could increase the spread of infection. This was addressed and bins were replaced by day 3 of the assessment but this had not been identified by the provider.

There was a designated housekeeping team, who ensured the home was clean and free from odour. A relative said that whenever, they visited the home was clean and tidy and this was echoed by a visiting health professional.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff carried out daily medicines checks and medicines were audited weekly as part of the provider's quality monitoring processes. However, an audit was completed on medication held in people’s bedrooms on the 19 January 2026 which found a number of discrepancies where medication was out of date in November 2025 and a large supply of topical creams that had not been dated when opened. This meant staff could not be assured these were safe to use. Improvements were needed to ensure medicines were within date and disposed of within a timely manner.

A new electronic medicines system had been introduced. There had been a number of concerns including issues with WIFI connectively and medication errors. It was evident these had been investigated and improvements made to ensure staff were competent in the system and to ensure people received their medicines as prescribed. The electronic system enabled the management team to monitor medicines and alerts were raised if this was missed.

Staff received training in medicines management, and their competency was checked before they were authorised to administer medicines.

People's individual medicines were stored in a secure cabinet in their rooms. This helped staff to provide a more person-centred approach to the administration of people’s medicines.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles.