Templemore Care Home

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 using our previous methodology 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 people’s assessed needs, and the management of risks associated to their care needs and safety risks that may affect the health, safety and wellbeing of people and others in the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager and 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.

Most people and relatives felt confident staff would be responsive to incidents. Accidents and incidents system was in place, but not all relevant information was recorded such as the events that led up to what incurred such as falls. The analysis of falls completed by the registered manager to identify trends was not reliable to prevent recurrence. This was raised with the provider, and they assured us monthly falls analysis were completed using information from the care planning system.

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.

Management and staff had good awareness when people needed additional support to make sure there was continuity of care. For example, when people were admitted to hospital or attended outpatient appointments, staff shared relevant information about the individual to ensure their needs were fully understood. A visiting health care professional told us staff sought advice and made referrals when people’s health was of concern such as skin damage.

The provider worked with people and health and social care partners to understand what being safe meant to them and how to achieve that. However, they did not always 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 always share concerns quickly and appropriately.

Some people and relatives told us they did not feel safe when there were staffing issues and agency staff were used. A relative told us their family member received inappropriate personal care and support. We shared these concerns with the provider who assured us they would investigate. We also informed the local authority. Staff were trained and confident to raise concerns with the management team and external agencies, if required.

People told us they felt safer with the regular staff who understood their needs. A relative said, “I feel [Person] is safe 100% [Person] says the staff are diligent. They call me; I’m kept informed about the smallest things there proactive of [Person] needs.”

The registered manager and 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.

Systems and processes were not robust enough to ensure risks to people were appropriately managed and mitigated. For example, people’s needs had been assessed but relevant information staff needed to know to mitigate risks was missing. Staff were aware of risks to people and their role to mitigate those risks however, we found shortfalls in how risk associated with people’s skin condition. For example, the district nurse requested a person needed to be repositioned 3 hourly but the care logs showed staff repositioned the person 5 hourly, placing them at increased risk of pressure ulcers. People with catheters and fluid monitoring was not well managed. For example, people had identified fluid intake targets but the intake targets were not always met and records did not demonstrate if any action had been taken. The lack of accurate, reliable and inconsistent information about a person’s hydration needs and continence needs put people’s health at increased risks, such as infections and dehydration. This demonstrated there was a lack of consistent management oversight to manage and mitigate risks to people. These concerns detailed above contribute to the breach of regulation in relation to safe care and treatment, and demonstrated a lack of consistent managerial oversight to ensure people’s needs were being met.

The feedback from people and relatives about how risks to people were managed was mixed. A person told us they had had falls and now used equipment that enabled them to move around safely. We observed staff using moving and handling equipment safely. Another person said, “I've been here 2 years, the carers are not bad, they could be better, could be kinder I suppose. When they turn me over in bed they could be gentler.” Records showed staff had worked collaboratively with the local authority to ensure this person needs were met safely by staff.

The registered manager and provider did not always detect and control potential risks in the care home. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found environmental risks which included an unsecured wardrobe, which could fall onto a person and the hot surface temperature of the bain-marie stored in the corridor which could cause burns and scalding risks. Staff were unable to confirm how long these risks had existed. We shared these concerns with the provider and action was taken. Regular fire, water and health and safety checks were in place but the issues we found had not been identified through the registered manager audits and checks. The provider needs to strengthen the oversight and monitoring of environmental risks.

People and relatives did not express any concerns with the safety of the environment. People had individual emergency evacuation plans in place and these were kept under review.

The registered manager's oversight of staffing did not always ensure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Prior to the inspection visit CQC had received concerns about risks to people due to staffing concerns. The local authority also received similar concern which they had raised with the registered manager and the provider. During our inspection visit people and relatives continued to express concerns about the staffing. A person told us,“They are under pressure, they do the best they can, always got 3-4 jobs on the go” and “I go twice a week. You hear call bells constantly ringing out which seems to upset the residents the constant ringing. When I have asked about staffing they say people leave and they can't replace them, there’s a lot of agency staff.” Staff expressed similar concerns. One staff member said, “Poor morale due to staffing levels, the morning shifts are the worst shifts. It is stressful getting people up, team leader does medicines and there are 6 doubles [people who require 2 staff to support them].” On 3 March 2025 there were not enough staff to meet people’s needs. We observed people’s safety was put at risk, for example, people living with dementia and at high risk of falling were in a lounge unsupervised by staff. There was no management oversight of staff deployment. We shared our observations with the provider, and they assured us agency staff were called but they arrived late. The following day the required staff were on duty, and they worked in a coordinated manner to meet people’s needs. This showed staff’s ability to meet people’s needs could vary depending on the staffing levels. The provider assured us they would improve the oversight of staffing levels and staff deployment. We will continue to monitor this.

New staff were recruited safely. Staff received appropriate training and updates to meet people’s specific needs. Staff were supervised and received feedback on their performance.

The registered manager did not always assess or manage the risk of infection. They did not always monitor staff practices to detect and control the risk of it spreading.

People were protected from the risk of infection by staff who followed infection prevention and control procedures. A person said, “I have a wash or a shower every day and staff collect my laundry and bring it back all clean and fresh.” A relative said, “It looks like a stately home from outside, it’s nice and smells clean.” People’s rooms were kept clean and bathrooms contained soap, paper towels and appropriate bins for waste. Where people were known to be at risk of infection, or were infectious, staff followed procedures to stop the spread of infection. We found cleaning products, hazardous to health, had been stored in the kitchenette was accessible to people. These issues had not been identified through the registered manager audits and checks. This was raised with the provider and were addressed immediately. Regular cleaning schedules were in place and audits were carried out by the management to monitor the cleanliness and staff practices. Feedback from the visiting external infection control and prevention team was positive about hygiene and cleanliness.

The registered manager and provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found the treatment room door was unlocked and medicine stored in the unlocked fridges were accessible. This was raised with the provider and action was taken immediately. Staff did not always record when prescribed creams were opened which have a short shelf-life. This put people at risk of receiving creams that could be out of date. People who were prescribed medicines to control stomach acid did not receive these in line with the medicine instructions, as these were not given before food and other medicines. These issues had not been identified through the registered manager audits and checks. This meant people were at risk of other medicines not being absorbed as they should to be effective. These issues were raised with the provider who arranged for staff to review their practices to prevent these risks.

Medicines were stored safely and there were appropriate arrangements for controlled drugs and the disposal of medicines. People told us they received their medicines as prescribed by trained staff. A person said, “I get my tablets on time and they change the patch (prescribed medicine in patch form) every couple of days; I've got no concerns.” Staff had guidance to follow about ‘when required’ medicines such as pain relief medicine. A sample of the medicine audits completed by the manager had identified shortfalls, but the action needed was not always recorded. Additional medicine audits carried out by the provider showed improvements were made.