SENSE - 25 Horsegate

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 remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked in partnership with people, relatives and professionals to understand what being safe meant in practice. Staff focused on improving people’s quality of life while protecting them from discrimination and avoidable harm. There was a clear expectation that concerns would be raised promptly. One staff member told us, “If an incident occurs between residents, they are separated to ensure everyone’s safety,” demonstrating a practical understanding of reducing risks and keeping people safe.

There were clear safeguarding systems and processes in place and staff showed confidence in recognising and reporting concerns. One staff member explained, “Safeguarding means making sure all individuals are safe and I would report any concerns to my manager,” showing awareness of their responsibilities. Staff also described challenging practice where needed, reflecting an open and accountable culture. Feedback from relatives supported this approach. One relative told us, “I have never had any doubt about his safety. Staff are so brilliant,” demonstrating confidence in how people were protected.

Where people’s liberty had been restricted, this was managed lawfully and appropriately through the Deprivation of Liberty Safeguards (DoLS). Staff understood the purpose of these safeguards and how they protected people’s rights. The provider was working in line with the Mental Capacity Act 2005 (MCA), ensuring decisions were made in people’s best interests and with the correct legal authority.

The provider supported people to stay safe by identifying and managing risks in a personalised way. Staff balanced safety with independence, enabling people to take part in meaningful activities without unnecessary restriction. Care plans outlined risks and support strategies clearly, supporting consistent care delivery.

Relatives confirmed they were involved in managing risks and reviewing care. One relative stated, “The care plan is updated as necessary. I am involved,” which demonstrated that people’s support was reviewed and adapted to meet their needs. Staff were very knowledgeable about people’s needs and adapted care to reflect changes, supporting safe and responsive practice.

Where specialist input was required, this was followed. For example, guidance from health professionals was used to support safe care delivery. This showed risks were not only identified but managed effectively with the right expertise.

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

During the inspection we identified risks such as missing radiator covers, which could cause harm. The provider acted quickly to address this and evidenced that the request had gone in to the maintenance team to get these fitted. This showed willingness to respond immediately to identified issues.

We also identified risks within some bedrooms, including unsecured furniture and loose cables. These concerns were raised with the registered manager and were addressed promptly. On our follow up unannounced visit on 28 May 2026, action had been taken and improvements made, demonstrating accountability and effective action to maintain a safe environment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. One staff member said, “I can speak to my manager in confidence, and the manager will handle it,” reflecting positive working relationships.

Staff received training and guidance to carry out their roles and management support was available. Relatives also spoke positively about staff competence, with one stating, “Staff are very well trained,” reinforcing that people were supported by skilled staff. Safe recruitment processes were followed, helping to ensure only suitable staff were employed.

There was some mixed feedback about staffing levels, with pressures at times due to absence or leave. The provider was aware of this and was recruiting to strengthen the team. Despite this, continuity of care was maintained through a consistent staff group who knew people well. The service also had access to experienced internal relief care staff that could pick up shifts at short notice.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.