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 rating inspection, we rated this key question Inadequate. At this inspection the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 provider demonstrated a strong and embedded learning culture across the service. There was a clear commitment to continuous improvement, with staff encouraged to reflect on practice and share learning openly. The provider had implemented a comprehensive accident, incident and near-miss log, which was consistently maintained and reviewed. This system enabled effective oversight and ensured that trends and patterns were identified promptly.

Learning from events was clearly disseminated to staff through team meetings, supervision and internal communications, such as daily flash meetings, supporting safer practice and reducing the risk of recurrence. Staff were able to describe how changes had been made as a result of incidents, evidencing that learning was not only captured but actively used to drive improvement and enhance the quality of care provided.

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 provider ensured that safe systems, pathways and transitions were well-managed for people who had often lived in the care home for many years. There was a strong emphasis on maintaining continuity, stability and familiarity, recognising the importance of established routines. Transitions, such as changes in health needs or hospital admissions, were carefully planned and managed to minimise distress and disruption. Staff worked closely with external professionals, including GPs and community health teams, to ensure timely and coordinated support.

Where changes were required, people and their relatives were involved and supported to understand decisions. Clear documentation and effective communication supported safe decision-making, helping to ensure people experienced seamless care throughout their journey within the service.

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 provider demonstrated robust safeguarding systems and a strong culture of protecting people from harm and abuse. Staff had a clear understanding of safeguarding processes and were able to confidently describe the different types of abuse and their responsibilities in reporting concerns. Training was up to date and reinforced through supervision and team discussions, ensuring knowledge remained current.

There were effective policies and procedures in place, and safeguarding concerns were reported appropriately and in a timely manner to relevant external agencies. Records showed that incidents were thoroughly reviewed, with learning shared to reduce the risk of recurrence. People told us they felt safe living at the service, one person said, “I feel safe here, staff keep us safe”. Relatives expressed confidence in staff to keep their loved ones protected, reflecting a proactive approach to safeguarding.

The provider ensured the requirements of the Deprivation of Liberty Safeguards (DoLS) were understood and appropriately applied. DoLS ensures people who cannot consent to their care arrangements in a care home are protected if those arrangements deprive them of their liberty Staff demonstrated awareness of when restrictions may amount to a deprivation of liberty and acted to ensure appropriate authorisation was in place. Applications had been submitted in a timely way, and any conditions were clearly recorded and followed. Care plans reflected the least restrictive approach and were reviewed regularly. This supported people’s rights while promoting their safety, choice and independence.

The provider worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to be involved in managing risks associated with their care, and robust systems were in place to guide staff in supporting individuals with complex health needs. For example, people with acute health conditions, including those requiring percutaneous endoscopic gastrostomy (PEG) feeding, epilepsy management and diabetes care, had detailed risk assessments, clear guidance and established protocols for staff to follow. These were designed to promote safety while supporting as much independence as possible. The interim manager provided effective clinical oversight and maintained regular engagement with health professionals, ensuring a collaborative, multi-disciplinary approach to reducing risks and managing people’s needs safely and consistently.

In addition, people with physical disabilities had comprehensive, person-centred risk assessments relating to their moving and handling needs, including detailed instructions for the safe use of complex mobility and specialist equipment. This helped to ensure staff were well-informed and people were supported in a safe way.

Where people chose to make decisions that could be considered unwise, such as not following guidance from health professionals including Speech and Language Therapy (SALT) or Occupational Therapy (OT) recommendations, these decisions were respected and fully explored. Comprehensive risk assessments were completed, clearly outlining the potential risks and the measures put in place to reduce harm while maintaining autonomy. There was clear evidence of capacity assessments and best interest processes where appropriate, alongside involvement of families and relevant professionals. This approach ensured people remained in control of their care and decisions, while risks were robustly managed and regularly reviewed to support their ongoing safety and wellbeing.

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.

The provider did not always ensure the environment was safely maintained, and this required improvement. At the time of inspection, the service had been without a dedicated maintenance person for several months, which had impacted the timely completion of routine repairs and environmental checks, such as fire safety checks. While some issues had been reported and actioned, others had not been addressed promptly, increasing the risk of environmental hazards. Although staff took reasonable steps to escalate concerns and mitigate immediate risks, the lack of consistent oversight meant that the environment was not always kept to a safe standard.

The provider acknowledged these shortfalls and had begun to take action to strengthen maintenance arrangements. A maintenance person had been recruited but not yet started at the time of the inspection. However, further improvement was needed to ensure the environment was consistently safe for people living at the service.

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.

Due to a recent restructure of the service, the provider had experienced a loss of some staff members, which had impacted staffing stability. However, they had taken proactive steps to address this through targeted recruitment drives to fill vacant posts. At the time of inspection, there were a number of staff at various stages of onboarding, including those shadowing experienced staff, newly commenced employees and others completing their induction training.

While this demonstrated a clear intention to strengthen the workforce, the high number of new and less experienced staff placed additional pressure on existing team members and had the potential to impact consistency of care. A staff member told us, “Staffing has improved, we don’t use as much agency staff as we used too. This is better for people. At times you have to show new staff what to do, but its getting better, although still need more staff. We have a lack of staff drivers.”

Despite this, rotas reviewed between April and May 2026 showed a reduction in the provider’s reliance on agency staff, which supported improved continuity for people using the service. Further work was required to ensure staffing levels, skill mix and experience were consistently sufficient to meet people’s needs safely and effectively. People told us staffing levels were regularly impacted. Comments included, “I don’t feel the staffing levels are sufficient, there is always someone off and they don’t have the staff to cover this. Then they use agency staff who don’t really improve things.” and “They’re short staffed sometimes, but its getting better.”

Staff were recruited safely, with appropriate pre-employment checks completed, including Disclosure and Barring Service (DBS) checks, references and verification of identity, to help ensure people were protected from unsuitable staff. Improvements had been made to the oversight and frequency of supervision, with records showing these were taking place more regularly and in line with the provider’s policy. Staff told us they felt better supported and had increased opportunities to reflect on their practice, discuss concerns and identify development needs. This contributed to a more confident workforce; however, continued embedding of these improvements was needed to ensure consistency and sustained impact across the service.

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.

The provider demonstrated effective improvements to systems to prevent and control the risk of infection. Staff followed appropriate infection prevention and control (IPC) practices, including the use of personal protective equipment (PPE), hand hygiene and maintaining clean environments.

The provider had engaged positively with external oversight, and an IPC audit completed by the local authority IPC team in January 2026 returned an overall score of 94%, with 87% achieved for the environment. Where minor environmental improvements were identified, the provider had taken timely and appropriate action, and all required actions had been completed at the time of inspection. This demonstrated a proactive and responsive approach to maintaining high standards of infection control. A further follow-up visit with the IPC team was scheduled for 2 July 2026, reflecting ongoing commitment to continuous improvement and external assurance.

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.

People received safe and effective support with their medicines, and medicines optimisation was managed well. Systems were in place for the ordering, storage, administration and disposal of medicines, and these were followed by staff. People’s medicines records were accurate and up to date, with clear guidance in place to support staff in administering medicines safely, including ‘as required’ (PRN) protocols where appropriate.

Where people required support with complex medicine administration, including PEG-fed medicines or time‑critical interventions during health emergencies, the service had robust, evidence‑based protocols in place. These ensured staff had immediate access to up‑to‑date clinical guidance and clear instructions, enabling them to carry out these tasks safely, consistently and in line with best practice. Staff had received relevant training and competencies in the management and administration of safe medicines and demonstrated a good understanding of people’s individual needs and the importance of medicines in maintaining their health and wellbeing.

Regular audits were completed to monitor practice and identify any areas for improvement, with actions taken to address any issues identified. Where required, the service worked effectively with healthcare professionals to review and optimise people’s medicines, ensuring treatment remained appropriate and person-centred.