White Acres

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 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 the safe management of medicines and safeguarding.

This service scored 56 (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 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.

The provider did not always learn effectively from concerns, incidents or information already available. Some issues had been known for several months but had not been resolved. For example, concerns about recording one-to-one support and the need to improve people’s goals had been discussed in a team meeting in October 2025. These matters remained unresolved at the time of our inspection in July 2026.

The registered manager was open and responsive to feedback during and after the inspection. They reviewed concerns and immediately introduced some clearer systems to support improvement.

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 did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. 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.

Staff understood the importance of safeguarding people from abuse and avoidable harm. However, systems did not ensure all potential safeguarding concerns were identified and reported promptly. This meant people could be placed at risk because concerns were not always recognised or acted upon promptly. We raised 1 safeguarding alert due to concerns found during the inspection, and asked the provider to raise another alert for an incident which had occurred but had not been reported to the local safeguarding authority prior to our inspection.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff and managers did not always work within the MCA. DoLS authorisations were appropriately applied for however conditions attached to authorisations had not always been met. Where providers do not meet DoLS conditions, people may experience unnecessary or inappropriate restrictions, have reduced opportunities to exercise choice and control, and may be deprived of safeguards specifically intended to protect their human rights.

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

Although some risk assessments were detailed, the service did not consistently involve people and those who knew them well in keeping risk information complete and up to date. Some records were not updated with the most current information until this was raised during the inspection. For example, 1 person had received updated guidance from health professionals on eating and drinking, however this had not been included in their care records until this was identified by the inspector. The registered manager immediately updated the person’s care records to reflect the latest guidance.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The home generally appeared clean, calm and comfortable. The gardens were well maintained and included a decking area and a space where vegetables were grown. A relative said the service had improved under the registered manager, telling us, “Everywhere looks brighter, cleaner, there are plants outside on the patio, staff do games out on the lawn for [people]. In all the years we haven’t seen evidence of that before.” People could personalise their bedrooms and make choices about the decoration and furnishing of communal areas.

The kitchen was clean and organised. Different coloured chopping boards were available to reduce the risk of cross-contamination. There were effective arrangements to meet a person’s gluten-free dietary needs.

The provider mostly made sure there were enough qualified, skilled and experienced staff, however, the provider did not always make sure staff received effective support, supervision and development and we identified an issue with the training around medicines for night staff.

Staff were caring and committed, but communication between shifts was reported as being inconsistent. Some staff did not feel adequately supported or directed, and 1 staff member could not remember when they last received formal supervision and felt it had been a long time.

Staff were recruited safely, and the provider had completed relevant checks prior to staff commencing employment. This included seeking references and completing a Disclosure and Baring Service (DBS) check.

Staff had received training in areas such as moving and handling, first aid, safeguarding, as well as the mandatory training to support people with a learning disability or autistic people.

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 found an unlocked clinical waste bin containing clinical waste. It was in an area accessible from the street and the surrounding bin area was also not secured. This meant there was a risk of the spread of infection. We also found a heavy build-up of limescale on taps around the service which would make them difficult to effectively clean and increase the risk of infection. The registered manager told us about the actions they would take to resolve these issues.

Staff had access to Personal Protective Equipment (PPE) and had received training in Infection Control.

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

The provider did not ensure there were staff trained in medicines administration on at night until this was raised during the inspection. We also identified a number of medicines which had not been administered to people because they were out of stock. The registered manager investigated this after the inspection, but could not establish whether medicines had not been ordered promptly by staff or whether there had been problems with the pharmacy. This meant people were exposed to the risk of delayed or missed medicines administration, which could have negatively impacted their health, wellbeing and the effective management of their medical conditions.

We also identified where people were prescribed and administered ‘when required’ medicines, the effectiveness of these medicines had not always been followed up in a timely manner. For example, a person had been administered a laxative however, at the time of the inspection which was 12 days after the administration of the medicine, the effectiveness had still not been followed up and recorded. In between this time, they had been administered another dose of laxatives, without staff being aware of whether the initial dose had been effective.

Although the service was aware of the STOMP agenda, records did not consistently demonstrate psychotropic medications prescribed for distressed behaviours were always regularly reviewed. For example, a person had been administered lorazepam, however, the inspection identified no Positive Behaviour Support (PBS) plan was in place at the start of the inspection. This meant staff did not have sufficient guidance on de-escalation techniques which worked effectively with the person and meant opportunities to evidence person-centred approaches and alternatives to medication were therefore missed.