Archived: Purbeck House 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.

This is the first assessment for this service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

At this assessment we reviewed all the quality statements for this key question. We found the service was in breach of legal regulation in relation to safe care and treatment including risk management, the safe management of medicines and environmental safety; safeguarding; staff training and fit and proper persons employed.

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.

There was a lack of understanding from the management team as to what met the threshold of a reportable event, which meant there was no evidence the provider was promoting a culture of continuous learning and improvement.

The provider failed to demonstrate that they investigated safety events, and these were not always reported. Opportunities to improve care from safeguarding concerns were often missed or not acted upon in a timely manner and lessons were not learnt to continually identify and embed good practice.For example, incident forms demonstrated several records of unexplained bruising and skin tear injuries to people. However, there was no further information to include what action had been taken by the provider to investigate these incidents or that the correct agencies had been informed.

Accident and incident records lacked details about each event and there was no evidence to show events had been analysed to identify any themes, trends or ways to mitigate the risk of further occurrences.For example, there was no follow up investigation or risk mitigation put in place for a person who had an unwitnessed fall in March 2025, there was only evidence of a body map indicating a minor injury. However, the person then had a further unwitnessed fall in April and sustained a head injury.

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 provider did not have an effective and safe system to ensure that people’s care records contained sufficient guidance for staff to follow. We found there was a lack of clear, up to date and consistent information about people's health needs where they may be receiving care from different services, such as the district nursing team.For example, a person was receiving regular visits from the district nursing team for the management of a wound. However, there was no care plan or risk management plan in place. This meant staff did not have any detailed information to guide and support them if the person’s wound deteriorated and what actions they would need to take.

Care records did not identify people's current needs, meaning information could not be easily provided to other professionals or hospital should the person be admitted. For example, one person had a diagnosis of Parkinson’s disease, yet, there was no information in their care records about this, or how it was being managed.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve this. 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 a relative told us they felt their loved one was safe and a person said, “I don’t have anything to worry about”, during our assessment we identified evidence whereby people were at risk of or were experiencing harm and or abuse. For example, we identified through completed incident forms, unexplained bruising and skin injuries to people. There was no evidence to demonstrate that these had been investigated to mitigate the risk of future occurrences.Therefore, where information of concern was raised, we were not assured timely investigations or actions were always taken where this was required to protect people from the risk of harm.

We found significant shortfalls in the provider’s safeguarding processes. Further, the providers systems and processes to manage incidents, accidents, near misses and potential safeguarding was not effective. For example, we identified a person who had an unwitnessed fall and sustained a head injury. Whilst paramedics were called the provider was unable to demonstrate any other action had been taken. There was no further documented information about this incident and no evidence was provided which demonstrated head injury monitoring had been undertaken. The staff and management team were unaware this needed to be completed.

There was a failure to take timely action, investigate and report concerns in an open and transparent way to external bodies such as CQC and the local authority safeguarding team. There was a lack of understanding and knowledge from the provider and management team in relation to what met the threshold of a notifiable event to the local authority and CQC.

During the inspection, due to the providers lack of safeguarding processes, we shared our concerns with the local authority.

The provider could not assure themselves that they consistently met their legal requirements where people were deprived of their liberty. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Whilst the provider had made applications for some people, we found examples where the provider had failed to make the required follow-on applications to the authorising body in a timely way. For example, one person’s DoLs expired in 2022 however, this was not identified and acted upon until 2025. This meant people’s freedoms were being restricted unlawfully.

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 were not safe because potential risks had not been identified or acted on. For example, none of the care records we reviewed, had detailed information about people’s past medical history, current health needs or diagnosis. Without this information the service failed to provide safe, effective care and monitor changes in people’s conditions. This information is vital to ensure appropriate and detailed care plans and risk assessments can be developed to support people’s ongoing safety and wellbeing.

For example, on review of care records, we found two people required a modified diet due to their risk of choking. We discussed this with staff including but not limited to, the manager, provider and cook on day 2 of our assessment visit and they were unaware of this requirement. This meant people were provided with meals and snacks at the incorrect consistency they had been assessed to require.

During our third and fourth site visits inspectors had to intervene when people assessed as requiring a Level 6 modified diet was provided with meals at the incorrect consistency. Therefore, these people had been placed at continued risk of significant harm.

Although the service completed ‘choking screening tools’ to establish risk of choking for people, risk assessments were not completed when these were indicated. Additionally, when the outcome of the completed tool indicated a referral to specific healthcare professionals was needed, this had not been done which meant people’s risks were not effectively identified, managed or reviewed, placing them at continued risk of significant harm.

Risks to people were not always effectively monitored. For example, on review of people’s care records we found two people’s records indicated they were at potential risk of constipation. There was no specific risk assessments in place for this condition and the elimination care plans did not contain any information about the management of constipation. We reviewed the bowel monitoring records for these two people and identified significant gaps in bowel movements, including occasions where they had not had their bowels opened for periods of 9, 8 and 7 days. This was discussed with the manager and provider of the service. Both were unaware of this and confirmed these records were not formally monitored. There was no evidence made available which confirmed actions had been taken during these periods to address or mitigate constipation. This meant people were at continued risk of significant harm.

On review of people’s care records, we found one person had a diagnosis of epilepsy. There was no care plan and risk assessment in relation to this condition to provide staff with information, guidance or advice on how to monitor, support and escalate concerns should the person become unwell or experience a seizure. When speaking with a staff member they told us, “No one living at the home has epilepsy.”

Further review of people’s care records demonstrated two people had a diagnosis of diabetes. For one of these people there was no care plan and risk assessment in relation to this condition to provide staff with information, guidance or advice on how to monitor, support and escalate concerns should they become unwell. For the other person the information in the care plan and risk assessment was out of date and did not contain clear and detailed information on how this was managed and monitored, and actions staff should take should an issue or concern arise. The lack of detailed and up to date information provided to staff placed people at significant risk of harm due to risk of receiving unsafe and inappropriate care.

During our inspection we were informed some people living at the home had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) which effects breathing. Care plans and risk assessments did not contain clear and detailed information on how this was managed, monitored, and actions staff should take should an issue or concern arise. This meant early signs of deterioration could be missed which would increase the risk of significant harm to people through lack of appropriate, timely medical intervention.

Further review of people’s care records identified some people were at risk of falling. This had not been identified by the management team and staff. Care plans had not been updated to reflect this risk, risk assessments had not been developed, and no action had been taken to prevent and mitigate these risks, such as consideration for additional equipment or the completion of referrals to health care specialists.

At this inspection we found some people were at risk of dehydration. There was not always information about how much people should aim to drink and there was no effective oversight to monitor the amounts of fluid people drank daily. Where people’s fluid intake had been monitored these showed some people had not reached their target fluid intake, yet there was no further follow up or action taken in response. Without effective monitoring and timely actions people were placed at risk of continued harm.

On further review of people’s care records, we found inconsistent and unclear information in relation to people’s needs and abilities. Although it was noted care plans had been reviewed regularly, the completed reviews had not resulted in the care plans being updated to reflect people’s current needs. Without detailed and up to date information staff were unable to ensure people’s needs would be effectively and safely met.

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

The provider and management team were not always clear of their responsibilities in relation to compliance with health and safety requirements. Systems and processes were not effective and failed to identify the concerns we found on this inspection.

The provider did not have effective systems to ensure appropriate water safety. For example, the provider failed to ensure people were appropriately protected against the risk of legionella. Legionella is a bacterium that can cause a severe type of pneumonia (legionnaires disease).There was no risk assessment in place to ensure staff knew what the legal requirements were and how to manage the risk of legionella. This placed people at significant risk of harm.

The provider failed to operate effective systems to ensure accurate recordings of all water temperatures were taken and what staff should do when temperatures were outside the safe ranges. Records indicated some outlets distributing water at 49°C putting people at risk of scalding.

The provider failed to ensure the home environment was safe by assessing and reducing risks related to fire. Shortfalls included gaps in required fire safety equipment checks and overloading of multiway extension leads which could overheat and cause a fire. There was a lack of evidence to demonstrate regular fire drills had taken place. Fire drills are important to adequately prepare staff for a potential fire, without these staff could potentially behave inappropriately if fire breaks out which placed people at risk of an unsafe evacuation.

We made some observations during our inspection that the environment was not always safe. For example, we observed all the wardrobes in the service had not been appropriately fixed in place which placed people at the risk of injury. We also observed that the provider had failed to ensure that window restrictors were in place on windows that required them within the home, such as, bedrooms, bathrooms and communal areas, some window restrictors in place were broken. This meant the provider did not ensure people were always appropriately protected from environmental risks.

The provider failed to ensure regular testing and servicing of equipment was undertaken in-line with the requirements. The provider was unable to evidence up to date servicing records for equipment such as, moving and handling equipment used to support people’s bathing. Whilst we acknowledge the provider had scheduled a service for a mobile hoist that was 3 months overdue, this was only arranged after we had identified the concern to them.

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.

The staff rotas we reviewed demonstrated there was between14 and 18 staff working at the home. The training matrix only listed 13 staff members in the workforce, therefore there was no detailed record of staff training for all staff. The training matrix provided during inspection did not demonstrate when staff training had been completed. Therefore, the provider could not be assured that staff had relevant and up to date training. On the training matrix we identified only 6, of the identified 13 staff as having completed falls prevention training and medicine training. Nine staff had received training in fire safety, 8 staff had received infection control and health and safety training, 4 staff had received training in malnutrition, 5 staff had received training in the mental capacity act and safeguarding adults and 3 staff only had completed learning disability awareness training.

The provider failed to provide evidence which demonstrated staff had received other essential training including moving and positioning and safeguarding children. This meant we could not be assured all staff had received training to equip them in their role and to ensure they could provide safe care to people.

Records of staff induction failed to demonstrate that staff received any required training during their induction period. We asked a staff member who had worked at the service for approximately one month if they had received training in safeguarding, infection control or moving and positioning and they said, “Not yet, I’m still waiting for a date for this.”

People and their relatives did not raise any concerns about the staffing levels at the home and felt staff were available when required. A person told us, “Staff are lovely, they are good” and another person said, “Staff are great, they really help.”

There were not effective systems in place to ensure safe recruitment processes were being followed. For example, of the 4 staff files we reviewed, one which was for a senior employee had extensive gaps in their employment history which had not been investigated, lacked references and did not contain any information which identified this staff member had the legal right to work in the UK. We requested, via email to both the provider and manager, on multiple occasions this information be sent to us. However, the information received did not address all the shortfalls found.Safe recruitment requirements were discussed with the provider who lacked knowledge and understanding of these requirements. This meant staff had been employed into the service without having all the required pre-employment checks in line with the statutory requirements and placed people at risk of receiving care from unsuitable staff.

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.

We observed the home to be relatively clean with no malodours. However, some soft furnishings were visibly dirty and some chairs had tears in the fabric which increased the risk of infections spreading due to these being difficult to effectively clean.

The provider was unable to demonstrate that the systems to prevent and control infection were effective. Although there were cleaning schedules for night staff, there were no records to demonstrate that housekeepers had schedules to follow throughout the day. This was confirmed by the provider and housekeeping staff.Without detailed and clear processes in place for staff to adhere to, areas of poor cleanliness may be repeatedly missed.

The provider did not provide evidence of an annual infection control statement or have a named infection control lead in compliance with best practice guidance.

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.

The provider failed to demonstrate that medicines were always stored safely. We observed the medicine trolley was not secure to the wall and the medicine keys left unattended on top of the trolley inside a folder. This meant people, staff or visitors could access the medicines inappropriately.

Temperature of areas in which medicine was stored were not being taken or recorded. Therefore, the provider failed to have effective systems to ensure medicines were consistently stored at the correct temperature. Medicines that required to be stored in the fridge were kept in a lockable box in the main fridge within the kitchen. We checked this box on all of our site visits and found this remained unlocked. Furthermore, whilst fridge temperature records were kept, these recordings did not include the minimum and maximum temperatures which are required to ensure these medicines consistently remain within a safe range. As this fridge was continuously in use the provider could not be assured these medicines, including insulin were consistently stored at the correct temperature. Although this was discussed with the provider and manager on 24 June 2025, during our visit on the 16 July 2025 we found the provider and manager had failed to take appropriate action to address this issue. This placed people at continued risk of harm due to receiving unsafe medicines.

At the time of our inspection there were no people requiring controlled medicines (CDs), which are medicines which are subject to strict legal guidelines around their use. However, from review of the controlled drugs register we identified that controlled drugs had recently been in the service. For example, CDs had recently been returned to the pharmacy yet the controlled drug register did not demonstrate that the management had signed these into the service when they were delivered. This meant that the provider failed to have effective oversight and auditing of these controlled medicines to ensure they were safely managed and accounted for.

Some people were prescribed 'as needed' (PRN) medicines, which require clear protocols for their use. Guidance in the form of protocols or care plans were not always in place and the ones we reviewed were not person centred or individualised. This meant the provider could not be assured PRN medicines were always administered consistently. There was insufficient recording as to why the PRN medicine had been administered or if it had been effective. These included medicines prescribed for people’s respiratory needs, anxiety, and pain relief. This information is useful in monitoring a person and deciding if they needed reviewing by the doctor. For example, out of 26 PRN medicines that were prescribed within the building, there were 20 protocols not in place.

A further example found during inspection was a person, who was prescribed the use of a transdermal patch, had no body map in place. Therefore, the provider could not be assured that the area of the body the patch was applied too was being alternated. This could lead to an increase in adverse reactions or potential overdose of a medicine.

Further, there were no Emollient risk assessments and management plans for people who were prescribed topical creams, where these creams are identified to be highly flammable.

Evidence was also found to demonstrate that there were no dates of 'opening' added to liquid medicines and topical creams, this included liquids that needed to be discarded after 30 days, or creams after 3 months. For example, we found a topical cream that was in use that did not have an opening date. When we checked the dispensing date, this was December 2022. This meant medicines could continue to be used even when it was no longer safe.

The provider could not demonstrate all staff were sufficiently trained or had been assessed as competent to undertake medicines administration tasks. We requested staff competencies on 3 occasions; however, the provider was unable to demonstrate that these had been completed.