63 Coronation 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. The service was in breach of legal regulation in relation to premises and equipment. The service environment was not kept clean or properly maintained.

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. The provider had processes to identify and record incidents, and records showed actions were taken to mitigate risk. Staff reported and documented incidents and understood their responsibilities to record events and monitor people to ensure their safety. The provider told us learning from incidents was discussed during handovers and team meetings, staff confirmed this. While there was some evidence of these discussions within team meeting records, we found some improvements were needed to ensure learning was consistently well documented. The provider told us they would address this. Staff told us communication was effective, and they were kept updated and informed of changes relating to people’s needs. A staff member said, “Communication is good.” People, relatives and staff told us they felt able to raise concerns with the provider. A relative said, “I think they are approachable, the carers they’re pleasant.”

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.The service supported people to attend health appointments and made referrals when additional support from health professionals was required. The provider had policies and procedures to support staff when working alongside other professionals. Health and social care professionals we contacted told us they had good communication and positive working relationships with the service, which supported continuity of care for people. A professional said, “I feel comfortable contacting the team to discuss any concerns, and they have been responsive and constructive in their communication.”

Whilst the provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that, the provider did not always share concerns quickly and appropriately. During the assessment, we identified safeguarding referrals which had not been notified to CQC. This is a legal requirement. We raised this with the provider who told us this was an oversight. Following the assessment the notifications were submitted. Despite this shortfall, appropriate referrals were made to the local authority in response to safeguarding concerns, investigations were completed and actions taken to mitigate risk. People and their relatives told us they felt safe being supported by the service. A relative said, “I think [person’s] safe there.” People appeared comfortable and at home within the service. The provider had an appropriate safeguarding policy which provided staff with clear guidance on how to safeguard people from abuse. Staff had received training in safeguarding adults and understood their responsibility to report any concerns. People can only be deprived of their liberty to receive care and treatment when there is appropriate legal authority. In care homes, this is done through a process called the Deprivation of Liberty Safeguards (DoLS), which forms part of the Mental Capacity Act 2005. At the time of the assessment, no person living at the service was subject to a DoLS authorisation.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.Overall risks associated with people's individual care and support were assessed and managed. For example, in relation to areas such as diabetes and self-neglect. Risk assessments relating to people’s mental health and specific behaviours were person centred and provided guidance for staff to support people in the least restrictive way. We identified support plans where the provider’s risk scoring tool was not consistently completed, this was raised with the provider, who confirmed this would be addressed. Staff demonstrated an understanding of people’s risks and told us support plans contained sufficient information to support safe care. A staff member said, “The most important information is there.” There was evidence of positive risk taking, with people encouraged to pursue their interests within the local community. People told us staff supported them to manage risks. A person said, “They like to make sure they got that right.” The provider shared an example of how the service had supported a person to manage risks associated with handling their own finances.

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.We were not assured the provider’s systems for managing maintenance were effective. We identified several areas requiring maintenance, including communal areas, where fixtures and fittings were in poor condition. For example, we observed a bathroom with fixtures in need of repair or replacement, as well as areas with mould present. Some areas of the service could not be cleaned effectively due to the need for maintenance. We found several actions identified by the provider’s maintenance team in October 2024, as well as actions identified by the fire authority in July 2025 had not been completed. Risks relating to radiators within the service had not been sufficiently assessed. We raised our concerns with the provider, who acknowledged maintenance work had not been completed as planned and informed us a new maintenance team had been recruited to address these shortfalls.We received mixed feedback about the service environment. Some people and relatives told us they were satisfied, while others, including professionals and staff, told us improvements were required as areas of the service were not always well maintained. A professional said, “The premises could do with some updating and decoration.” We were told some refurbishment projects had been completed, including a new kitchen and bathroom within the previous 12 months. During our site visits, roof repairs were observed in progress. A staff member said, “It’s an old house, they are slowly trying to get through things.” During the assessment, the provider responded promptly by developing an action plan to address outstanding maintenance tasks. Following the assessment the provider told us the work had been completed. The provider carried out other building safety and equipment checks, including gas and electrical inspections, to ensure the safety of people living in the service.

Whilst the provider made sure there were enough skilled and experienced staff, they did not always make sure staff received effective support and development opportunities. During the assessment, we identified staff supervisions and appraisals had not been kept up to date or completed in line with procedure. We identified some gaps in staff induction records. The provider told us they would take action to address this. Despite these shortfalls, most people and their relatives spoke positively about the support provided and told us there were usually sufficient staff available. A person said, “Brilliant. I get along with them.” The service was supported by a small, established team of staff, with any gaps in the rota covered by existing staff or regular agency staff. We observed there were sufficient staff available to meet people’s needs. Most staff told us staffing levels were improving and were sufficient. A staff member said, “Now it’s fine, we have different colleagues, it’s enough.” Staff told us they felt supported and had access to sufficient training opportunities, including training to meet the individual needs of people using the service. Records showed training was being refreshed in line with the provider’s procedure. We found staff recruitment records were complete, with appropriate checks completed prior to staff starting work. These checks included criminal record and employment history checks to ensure staff were suitable for their roles.

The provider did not always assess or manage the risk of infection. During the assessment we identified areas of the service which required cleaning including communal spaces and bathrooms. Aspects of best practice relating to infection control were not consistently followed, for example, hand wash was not always available in bathrooms and bins did not always have lids. Records showed daily cleaning was taking place; however, checks of bathrooms and deep cleaning needed to improve. We received mixed feedback regarding cleaning at the service. Some people, relatives and staff told us the service was kept sufficiently clean. A relative said, “Nice and clean inside.” Whilst others told us improvements were needed. Comments included, “It could do with more of a deep clean”, “It’s not that clean, not really.” Staff had completed relevant training and had access to personal protective equipment (PPE). The provider’s infection prevention and control policy reflected national guidance. People were encouraged to be involved in cleaning their own rooms to promote their independence in this area. One person said, “[Staff] check, make sure I’m doing stuff like my room.” We raised our concerns with the provider, who told us they would implement frequent bathroom checks and a planned deep cleaning schedule for the service, to ensure cleaning standards improved. During the assessment the provider confirmed bins with lids had been placed in all bathrooms.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines policies supported the safe administration of medicines. We reviewed medicines administration records for some people and found the recorded stock levels matched the medicines held. Most people and their relatives told us they were satisfied with the support provided with medicines. A relative said, “They do that very well.” Protocols were available to guide staff in the use of PRN ‘as required’ medicines, however we advised some further detail should be included within these records, the provider told us they would take action to improve these. Where people were prescribed time specific medication to support their mental health condition, the service had appropriate risk assessments. Staff stored medicines safely and securely and told us they felt confident to administer people’s medicines. Staff received medicines training and were assessed as competent before administering medicines. A staff member said, “Everybody receives training and a competency assessment.”