Archived: Quenby Rest 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 we rated this key question Good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to safe care and treatment, including a lack of suitably qualified, competent and experienced staff, poor infection prevention and controland safeguarding people from the risks of harm or abuse.

This service scored 25 (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.

Safety was not seen as a high priority. Risks were not being recognised, learnt from and dealt with promptly to put things right. There was a lack of robust audit and governance arrangements in place to effectively review and analyse data relating to falls, incidents, accidents and safeguarding concerns. Incident and accident logs were not sufficiently completed to reflect actions taken, lessons learned or change in practice to prevent future occurrences. There was no system in place to learn from safety events. For example, where things had previously gone wrong in relation to improving the safety of people with swallowing difficulties from the potential risk of choking.

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.

There were no processes in place to ensure the safety and continuity of care for people discharged from hospital to the service on the RTH scheme. Admissions to the service and discharges from hospital were not managed well. The registered manager had not completed a robust assessment of people’s needs before accepting them into the service to ensure their specific needs could be met. Information from hospital transfer / discharge letters was not transferred into a working plan of care at the time of admission to the service to ensure their needs were fully understood and enable staff to deliver continuity of care in a safe way. There was no robust system in place for handing over and sharing information to staff about people moving into the service to ensure they received person-centered care and treatment appropriate to their needs, personal preferences, and which protected them from harm, or the risk of harm occurring.

The service had not been set up to support people’s independence. Although the service had a range of hoists to aid safe transfers, there was no specialist or adaptive equipment available to promote people’s independence. The kitchen area assigned for the RTH project, was not fit for purpose., The kitchen was not equipped for the RTH reablement assistants or care staff to support people to improve their confidence to make snacks and drinks in preparation for returning home, in line with their therapy goals. This area was also shared with the activities worker and the hairdresser.

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

Managers and staff did not have a sufficient understanding of safeguarding. They did not work collaboratively with the Local Authority safeguarding team, or CQC by reporting safeguarding matters, promptly. The safeguarding log was not up to date and only recorded outcomes from Local Authority investigations. There were no formal systems or processes in place to ensure safeguarding concerns were reviewed to improve care for others and make sure people were protected from the risk of harm, abuse and neglect. Managers were not effectively investigating safeguarding concerns or documenting their findings, actions and improvements made as a result of a safeguarding concern. Failure to ensure safeguarding concerns were dealt with thoroughly placed people at risk of abuse, neglect and the human rights not being upheld.

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.

Risks to people’s safety were not being identified and managed well, in a timely way. Therefore, risks to people’s safety were overlooked, or not responded to promptly before safety events occurred with the potential for people to come to harm. Fire safety concerns, including replacing fire doors identified by external contractors in August 2024, had not been addressed when we visited in March 2025. Although the provider took immediate action following our visit to carry out the works needed and mitigate the risk to people’s safety, these issues had not been identified as a priority.

Managers were failing to assess the risks to the health and safety of people using the service and do all that was practicable to mitigate any such risk. People's care plans and associated risk assessments lacked detail for staff to guide them on the type and level of support the person needed to meet their needs and mitigate any risks to their safety. This resulted in people not receiving consistent support from staff to manage risks associated with their health and wellbeing. Staff lacked knowledge about risks to people, including swallowing difficulties, and what equipment to use when supporting people with their mobility. Where people communicated their needs, emotions or distress through their behaviours care plans lacked personalised strategies and good practice approaches for staff to follow, to reduce the persons anxiety, distress and prevent harm to themselves, and others.

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

People were not cared for in a safe environment. There were no effective arrangements in place to check the safety and upkeep of the premises, and address issues that presented a potential risk to the health and safety of people using the service. A health and safety audit completed on 30 January 2025, was not properly completed and failed to provide any details of hazards found or measures put in place to reduce them. This included, unsecured wardrobes, which posed a potential risk of harm if pulled or toppled over, and fire safety concerns previously identified in the fire risk assessment completed in August 2024.

The environment looked tired and was poorly maintained. The cleaning cupboard and sluice room were cluttered, and not clean. Where a toilet had been removed the waste pipe hole had been filled but left a large gap in the lino which was not flush with the remaining flooring. The sluice / sink had missing or cracked tiles above. The laundry room was small and cluttered. There was water damage on the ceiling and the floor covering was incomplete. Parts of the floor were missing in the corner by the sink unit, and the space behind the bins was bare concrete making it difficult to clean. Incomplete flooring, and missing tiles can create a breeding ground for bacteria and other microorganisms, potentially leading to increased risk of infection.

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 service worked in partnership with the Local Authority for the RTH scheme providing reablement support to 5 people at a time, over a 4 week period to support them to return home following discharge from hospital. Four people were on this project at the time of each visit to the service. The remaining 17 people were fully reliant on care staff to meet their needs and keep them safe.

During 3 visits to the service, we found there were not enough staff to safely support people and provide good quality care. The dependency tool used to calculate the number of staff needed did not realistically consider the varying needs of people, including those requiring enablement support whose needs fluctuated week by week and dementia related needs. In accordance with the RTH project contract the Local Authority provided 1 reablement care worker to oversee and monitor each person with input from a physiotherapist. Included in the contract was additional funding to cover the costs of providing staff to support the contracted reablement worker. However, staff were not routinely allocated to support the contracted reablement workers with people’s therapy plans and goals. This placed added pressure on the reablement workers and failed to ensure a joined-up approach to ensure people were supported appropriately to achieve their goals and return home as soon as possible.

Insufficientstaff were employed to keep the home clean and hygienic.

Staff were not provided with the support, training, professional development, supervision and appraisal necessary for them to carry out their toles and responsibilities effectively.We identified shortfalls in training and staff’s understanding of people’s specific needs, particularly where people were living with dementia. Staff, including catering staff were not clear about how to prepare foods in line with the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines, which puts people at risk of harm. IDDSI sets out the global standard with terminology and definitions to describe texture modified foods and thickened fluids used for individuals with dysphagia of all ages, in all care settings.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Systems to assess and manage the risk of infection were not being managed in line with current Department of Health guidance designed to help social care providers limit the risk of cross infection. We found infection prevention and control (IPC) measures were poor, which placed people at risk of acquiring infection. The premises were unclean and unhygienic, including people’s en-suite facilities, the laundry and the cleaning cupboard and equipment. There was no effective policy setting out the correct use and management of cleaning equipment and handling of laundry to prevent the spread of infection.

The Local Authority Integrated Care Board (ICB) IPC team shared their findings with us following their audit of Quenby Rest Home on 13 March 2025. Their report listed actions needed to improve infection control within the service. We found the same issues when we visited the service on 20 March 2025. No action plan had been created demonstrating how the IPC failings in the service were to be addressed with time scales. The lack of effective infection control systems to minimise the risks to people placed them at greater risk of infection and associated implications to their health.

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 service did not always make sure people’s medicines were administered and managed safely, in accordance with prescriber instructions and best practice guidelines. There were no systems in place to ensure medicines prescribed, as required (PRN) were administered correctly and accounted for. Where PRN medicines such as paracetamol, or inhalers to control asthma had been prescribed, not all people had a protocol in place to direct staff, when to administer these medicines, or signs to look for to assess if the person was in pain or having difficulty breathing. Where people were prescribed sedative medicines to help relieve symptoms of anxiety and agitation PRN protocols did not contain guidance for staff on what interventions should be tried before administering the medicine, as a last resort.

People prescribed anticoagulant (blood thinners) medicines are at a higher risk of bleeding, especially internally, which can be life-threatening if they fall. Six people were taking anticoagulant medicines to prevent blood clots and prevent strokes but had no care plan, or protocol in place to guide staff on potential risks from their prescribed medicines, including the need to seek immediate medical attention, if they had a fall, even if they did not appear to be bleeding.