King Street - Care Home Physical Disabilities

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

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 inadequate. This meant people were not safe and were at risk of avoidable harm.
The service was in breach of legal regulation in relation to safe care and treatment, medicine optimisation, safe and effective staffing.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service did not demonstrate a strong culture of learning and continuous improvement, with limited evidence of robust systems and processes to ensure effective oversight of accidents and incidents. Furthermore, investigations following incidents had not been completed to reduce further risks of harm. For example, one person sustained a significant injury in April 2025; however, there was no investigation by the provider, lessons learnt analysed or actions taken following the incident to ensure further risk mitigation was implemented. Additionally, the providers lessons learnt log which provides oversight of accidents and incidents had not been completed since March 2025. This meant managers of the service did not have sufficient oversight of potential avoidable risk.

Staff did not consistently report incidents, including near misses, which limited opportunities to reflect and make meaningful changes. This meant opportunities to reduce risk, learn from events and improve safety culture were frequently missed. There was a lack of systematic reflection or dissemination of lessons learned. This hindered the organisation’s ability to enhance the quality and safety of care. Without effective mechanisms to review and respond to adverse events, the service failed to embed continuous improvement and ensure that risks to people were consistently identified and mitigated.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The service did not have effective systems in place to support safe transitions into care. One person had recently moved in but this admission did not ensure the appropriate support, staffing, or planning to ensure a successful transition. Staff lacked the necessary training in positive behaviour support, and there was insufficient oversight to monitor and respond to the individual’s needs.As a result of poor staff deployment and insufficient training, the person experienced distress which impacted and disrupted other people’s lives. For example, because people may be injured, they did not use communal areas and remained in their bedrooms throughout the day. The provider failed to deliver care that was safe, person-centred, and well-coordinated. This indicated a lack of robust pathways and governance to manage admissions safely and responsively.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Although policies were in place, they were not consistently implemented or managed in line with organisational expectations. There was a lack of effective systems and processes to identify and escalate potential safeguarding concerns. Leaders were not sufficiently alerted to risks, and assurance could not be provided that people were being safeguarded appropriately. The regional manager told us “We know we need to develop better oversight of risk; it is something we are working on. Staff have been supported to ensure all concerns are reported to team leaders or managers.” However, several staff told us they were unclear of the reporting process and were unsure of their roles and responsibilities regarding completion of records and reporting systems. We found significant delay in responding to and reporting incidents which occurred within the service, for example, a significant incident which left a person with a serious injury in April 2025, had not been reported to relevant organisations to safeguard the person and mitigate further risks until June 2025. This meant there was missed opportunities to protect individuals from harm.

The managers upheld their responsibility to ensure people who were deprived of their liberty had this legally authorised or an application to the courts had been made.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People who required support with acute health care tasks such as the management of PEG (enteral feeding tube which is inserted into the stomach), epilepsy, and diabetes were delegated by clinical health professionals to the staff team without sufficient oversight or assurance. Following delegation, the provider failed to ensure up to date risk management plans were in place or some records used by staff contained outdated or conflicting information, which led to confusion among staff and a lack of clarity in care delivery. As a result, people did not consistently have access to essential equipment or rescue medicines. Managers were unable to locate essential risk management plans or protocols required to be in place to guide staff in their response to health concerns. Several staff were unaware of people’s essential protocols when managing health needs, placing them at significant risk of harm if an emergency occurred.

Planning and risk management for people who experienced distressed behaviours were also insufficient. One person was left isolated during significant periods of distress due to a lack of staff training and clear guidance in Positive Behaviour Support (PBS). This failure increased the risk of harm to the individual and others using the service.

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.

Equipment used to move people had been adequately serviced to ensure people could be moved safely. The environment was adapted for people who required adjustments to access the environment freely. |For example, the kitchen facilities could be altered for people who use wheelchairs to access cooking equipment and sinks safely. Environmental audits were completed weekly by the management team and concerns were escalated. However, changes with the maintenance team meant some works to the environment had not been addressed timely.

Several relatives raised concerns about the lack of maintenance of the grounds and their family members rooms. Comments included, “[person] has a hole in the wall of their room, we have raised this several times, but nothing has been done about it” and “The grounds are not cared for, since the maintenance person has changed roles, the gardens have been neglected”.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

We observed poor staff deployment across the service, which left people unsupervised with limited access to staff support should they require it. Additionally, the service did not consistently ensure communal areas were safe and appropriately staffed. Inspectors observed periods where staffing levels were insufficient to monitor and support people who were unable to communicate or move independently. During these times, individuals were left in potentially unsafe environments, particularly when another person was in visible distress and displaying behaviours that could pose a risk to others. Staff did not respond promptly, and people remained in these situations for significant periods without intervention. These issues placed people at risk of harm and demonstrated a lack of oversight and planning to ensure staff were competent, informed, and deployed in a way that met people’s needs.

Staffing arrangements were not safe or effective. We reviewed rotas between October 2025 and November 2025, significant gaps were identified. The management team told us “We have recently implemented a staff member who will deliver peoples 1:1 commissioned hours. We are actively recruiting. In the meantime, we are covering a lot of hours using agency staff.”

There was a high reliance on agency staff, many of whom told us they had not read people’s care records and were unfamiliar with individual needs and risk management plans. This meant not all staff working directly with people had sufficient knowledge or understanding to reduce the risk of potential harm to people or provide care tailored to their individual preferences.

Staff had not received essential training or had their competency assessed by a clinical lead in both the safe management of acute health conditions and positive behaviour support. This meant they were not equipped to respond appropriately to behaviours that challenge or manage health needs safely.

Although staff were recruited safely and relevant checks were completed, permanent staff had not received regular supervisions in line with the provider’s policy. At the time of the inspection 25 staff were overdue a supervision with a manager. Several staff told us they felt emotional and exhausted, which further impacted their ability to deliver safe and effective care.

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.

Infection prevention and control practices required significant improvement. A recent visit from the Local Authority IPC (Infection Prevention Control) team raised serious concerns with the cleanliness of the home including people’s health equipment and manual handling equipment. The IPC team identified further work was required to ensure systems were embedded to implement effective IPC procedures.

Inspectors found not all essential actions had been addressed by the provider. For example, hand sanitisation stations around the home were empty, limiting opportunities for staff and visitors to maintain good hand hygiene. Additionally, staff were seen supporting a person to eat a sandwich without wearing gloves or an apron, which did not follow best practice for food hygiene or personal care. These lapses in infection control increased the risk of cross-contamination and demonstrated a lack of oversight in maintaining a safe and hygienic environment. We spoke with staff who told us they did not know they must wear PPE (personal protective equipment) when supporting people to eat. Staff promptly donned appropriate PPE following us raising concerns.

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

Systems were not in place to safely administer and store medicines. We reviewed records for two people who were receiving their regular medicines and nutrition via PEG (Percutaneous Endoscopic Gastrostomy (a feeding tube inserted directly into the stomach through the abdominal wall). However, the service had not ensured up to date information was available from the specialist enteral nutrition team to support staff in how to administer the medicines and nutritional feed safely. This meant people were left at risk of not receiving their medicines and nutritional supplements safely and according to their assessed requirements.

Care plans and risk assessments were not reflective of people’s current medicines needs despite recently being updated. They also lacked information for staff to support people with complex needs, such as their mental health or those on blood thinner medicines. This meant staff were not supported appropriately to care for people at the service.

Some care plans for people with diabetes and epilepsy stated emergency rescue medicines were in place in the event of hypoglycaemia (low blood glucose levels) or seizures. However, we found that this was not the case. This meant there was a risk that in the event of an emergency, the correct actions may not be taken, increasing the risk of harm.

Staff did not always have the required training to carry out administration of certain rescue medicines safely. This meant the service could not be assured that staff would be able to manage these tasks safely.

Medicines audits were carried out weekly, however we found these were not fully completed and had not identified the issues found on inspection. This demonstrated a lack of medicines oversight at the service.

We visited the service the following week to follow up the issues found on our first visit. We found some actions had been taken, for example, protocols were now present for people who had PEGs in place, and emergency rescue medicines had been requested by the GP. However, staff were unaware of these actions due to a lack of managerial understanding about their importance. This meant staff working directly with people’s medicines had not been updated and relevant information had not been shared with them to ensure safe medicine management.