Shaftesbury New Court Place

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 the last inspection, we rated this key question as good. At this inspection this key question 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 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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

People and relatives told us the management and staff team asked for their feedback and made changes if needed.

Learning from accidents, complaints and inspections was taken and shared with the staff team in most cases. Most staff told us, and we saw from records, this was discussed at handovers, team meetings and as part of day-to-day discussions. A staff member confirmed, “The management team are very good at updating staff on concerns, complaints lessons learnt, updates in policies and procedures.” However, staff felt handover could be improved when staff have been off a few days but that it was being worked on. Some staff told us information was not always shared at care staff level. This was an area for improvement. The management team acknowledged there was ongoing work with communication.

Clinical and staff meetings discussed incidents, accidents, changes to needs and events. When these happened, action was taken to address this. This included training, spot checks, referrals and changes to equipment.

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 received a preadmission assessment completed prior to moving into the service. Records were held on file, and information was to be shared with healthcare professionals as needed. This was used to help inform the care planning process. However, we received some feedback that a recent admission to the service had only verbal instruction given with a care plan not being in place for a week. We discussed this with the registered manager who told us, “New Court Place has had only one new resident [recently], there would have been a period of time when we were building this resident’s care plan and were learning about this resident. To facilitate a better understanding of this person’s care requirements, the keyworker and several other enabling support workers went to visit the previous care home on a number of occasions to better understand this individual.”

There was positive feedback from visiting professionals. A visiting professional said, “They accommodated a meeting with me, even though I arrived unannounced, and they had a good knowledge of the problems facing the various residents. My impression is that the management and staff are genuinely concerned about the wellbeing of their residents. There is good rapport between the residents and the staff, and the residents seem relaxed and happy. Our interactions with the previous manager were limited, but we have developed a good relationship with [deputy manager] and more recently [registered manger]. They are responsive to emails, and proactive in following up on issues for their residents. The management team have helped us facilitate service user forums on their premises and also to run clinics there for our service users so that transport is not an issue, and we can see more residents.”

The provider had not always shared concerns quickly and appropriately with the Care Quality Commission (CQC). 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.

Safeguarding concerns were processed and recorded appropriately in most cases. However, we noted records showed some people had experienced potential safeguarding incidents and while they were shared with the local authority, they were not notified to the CQC as required. We discussed this with the management team who assured us it was a misunderstanding in reporting requirements, and they would ensure this happened going forward.

Most people told us they felt safe living at the service. However, 1 person told us they did not feel safe. This related to concerns about night staff numbers and going to hospital without a staff member. We spoke with the management team about these concerns who gave assurances about night staffing and an explanation regarding the protocol for staff support for hospital visits.

Relatives felt their family members were safe. A relative told us, “We feel that our relatives’ needs are met and they are safe when supported by the staff.” Interactions between people and staff indicated people were comfortable with them. However, we received some feedback from a relative stating that people, relatives and staff did not all feel safe to speak up for fear of repercussions. We discussed this with the management team who told us in addition to spending time around the home there were anonymous reporting opportunities if the needed to. We spoke with people as part of the inspection visit and raised awareness of how to report concerns to us.

Staff told us they knew how to recognise, and respond to, abuse. Staff told us they would speak up and report concerns when needed. A staff member said, “I would follow safeguarding procedures and report the concern immediately. I am aware of the signs of potential abuse and understand my responsibility to raise concerns.” Another staff member said, “I´ve never seen or needed to raise concerns in relation to abuse.” Staff were observed being kind and patient in their approach when supporting people. People were relaxed when interacting with staff which indicated they were comfortable with staff.

Staff received training in relation to safeguarding people from the risk of abuse and information was displayed around the home.

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. However, changes to a hospital policy increased risk for people.

People had individual risk assessments, and these gave guidance to help ensure staff supported people safely and were regularly reviewed. This included pressure care management, use of equipment such as wheelchairs, falls safety including the use of bedrails and choking prevention.

Staff were able to explain how they supported people to help prevent risks. For example, preventing falls, skin damage and choking.

People and their relatives told us they felt staff supported them safely. A relative said, “We feel that our relatives’ needs are met and they are safe when supported by the staff there.” Although there were concerns about people’s safety and welfare when going to hospital now staff were no longer staying with them due to a change in policy. We discussed this with the management team who told us there had been a change in protocol which could have been communicated better. They state the change relates to mainly at night, in an emergency they may not be able to send a staff member with a person due to risks to the service if left short staffed. They said when they could send someone, they would. They were working with the local authority to look at funding arrangements for this.

Staff told us about risks to people and the action they took to help reduce those risks. For example, in relation to falls, behaviour support, dietary needs and changes in health needs.

We saw people were able to move around safely, staff responded to calls for assistance and carried out regular checks. Staff ensured people were sat up when eating and drinking. There were call bells accessible for those who were able to use one and bed rails had protective bumpers fitted.

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.

Our observations found there were some areas of the service that needed attention. For example, updates to bathrooms, decoration and fixings such as curtains, plug sockets and pipes. The service improvement plan had an overview of some of these issues, but work needed to be ongoing to address the shortfalls. Some people and relatives told us they had been waiting for work to be completed. We discussed with the management team about how they would include people in decisions about what they might like to see change in the environment to make it more homely rather than focusing on needs alone.

People had access to call bells to alert staff to their need of assistance.

Staff were aware of hazards and how to reduce these. Most staff had attended fire drills, there were regular drills carried out, and people had individual evacuation plans. A staff member said, “Yes I have attended a fire drill.” However, another staff member told us they had not completed a fire drill. We sought assurances from the registered manager to help ensure gaps in practice drills were addressed swiftly. The deputy manager discussed fire drill practice with staff on a recent night visit.

There was firefighting and evacuation equipment in place.

There were regular checks and risk assessments carried out on the environment and equipment to help ensure the appropriate servicing was carried out, and everything was in working order.

The environment was purposeful to ensure it met the access needs for people who moved around in wheelchairs. Bedrooms were personalised. However, in the communal area, while there was not a need to have standard chairs and dining chairs, more could be done to help the building feel more homely. The room used for sensory needs required more development to ensure it was beneficial and comfortable for people. It included 2 empty soft play/padded areas, some switches on the walls and some fabric sensory squares. Consultation with people about how to use this space would be beneficial.

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.

People gave mixed views about if there were enough staff to meet their needs. A person said, “Yes they come, and they tie my call bell on so it doesn’t fall off and I can reach it.” A person said at times they needed to wait if staff were busy. There were concerns about at night if staffing was not fully filled. We discussed this with the management team who told us, they had developed a positive relationship with an agency who could supply staff quickly. They told us there had not been recent gaps in staffing.

Relatives said they felt there were enough staff, and staff were trained for their role. A relative said, “There is generally enough staff to support my [person’s] needs. Currently they need to be accompanied by staff when they go out and this cannot happen as often as they would like, however a particular effort has been made to ensure they [go out weekly for planned activity].” However, people and relatives were not happy with recent changes that staff would not escort people to hospital.

Staff gave mixed views about if there were enough of them to meet people’s needs in a person centred and timely way. Some said staffing did not always ensure 1-1 support was consistent and people had the opportunity for engagement and going out. A staff member said, “In my experience, staff work hard to meet people's needs and provide support in a timely manner.” Another staff member said, “I believe there is more than sufficient staff on duty for all shifts. Some shifts run smoother than others and where they are not so efficient, some things may be delayed. It has improved and staff are improving their teamwork, the team lead is key to an effective shift.” However, another staff member said, “No, not enough staff to meet people´s needs, and care is always late.”

During our visit, staff were mostly prompt when people requested support. We did note a person was waiting for an hour to get up for the day. A person told us a person living at the home had gone to hospital and this was why they were ‘short staffed’.

Staff were carrying out regular checks, but they were busy proving personal care so there was limited interaction outside of this.

Staff told us they received enough training and support to carry out their role. A staff member said, “I feel that I receive appropriate training and support to carry out my role as an Enabling Support Worker. I have completed mandatory training, and my competencies are checked to ensure I am working safely and effectively. I also receive supervision and support from management when needed.” Another staff member told us they were expected to complete training when not at work. We discussed this with the management team who told us the previous manager had stopped paying staff for online training at home, but this had been recently reinstated.

We reviewed the training provided and saw this covered all mandatory subjects. There were also competency checks to assess staff knowledge and skills. Recruitment followed a process carrying out checks to help ensure staff were suitable to work in a care setting. These checks included criminal record checks, verifying applicants’ identities and written references. Full employment history was also checked with any gaps needing to be explained.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly if and when needed in most cases. Some checks needed to be more robust.

There were IPC audits and checks in place. However, we noted an audit completed in July 2026 ticked ‘yes’ for everything being as it should be but then included comments such as, ‘wheelchairs need deep cleaning’ and ‘mattress has a tear in it’. This meant that score of the audit may be misleading to the governance process.

People’s bedrooms and communal areas were kept clean. Staff were practicing IPC in their day-to-day roles. We observed correct handwashing and use of personal protective equipment (PPE). There was a supply of PPE available in dispensers on the wall which included 3 sizes of gloves, facemasks and hand sanitiser.

Staff knew how to practice good infection prevention and control (IPC). A staff member said, “I have received infection prevention and control training and apply this in my daily work through good hand hygiene, use of PPE where required and following infection control procedures.”

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

Medicines systems had clear records and processes. However, the temperature records for medicine storage had several gaps noted.

People received their medicines in accordance with their needs and as the prescriber intended. However, we found 1 missing signature on the records we reviewed.

Staff responsible for managing medicines were aware of safe practice. We note that some areas, such as needed (PRN) protocols would benefit from having more person specific details included. Covert medicines should always consult a pharmacist as the way a medicine is given, for example crushed, can affect how the body absorbs it, however this was not recorded as being carried out. The deputy manager told us they worked closely with the pharmacist and provided us with a record demonstrating this.

We reviewed a sample of audits and found these were checking the appropriate elements, such as quantities, entries and storage of medicines. Actions were in place were shortfalls identified and these were signed off when completed. There had been medicines errors which had been reported to the local authority and investigated. These mainly related to missed medicines or gaps in signatures. The management team told us this linked mainly to a previous agency and nurses provided. They said this had improved under the current nurses provided.