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 inadequate. At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and staffing. Not enough improvement had been made at this assessment, and the provider remains in breach of these regulations. In addition, we found the provider was in breach of legal regulations in relation to staff recruitment.

This service scored 31 (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.

At our last inspection, we identified serious concerns with people’s safety and shared the findings with the provider to enable them to learn and improve. At this inspection; the provider had failed to make improvements, lessons had not been learned, and significant areas of concern remained, particularly in relation to fire safety and risk of choking.

Safety incidents were being reported and recorded but did not demonstrate a full review of the incident was considered to identify root causes, inform future actions to mitigate risk and improve outcomes for people. For example, where there had been an altercation between 2 people, resulting in 1 person receiving a minor injury it stated the lessons to be learned were to ‘encourage people who did not get along to sit away from each other’ and ‘noisy environments can cause further agitation’. Another incident record reported a bruise of unknown cause noted on a person’s elbow. The lessons learnt stated ‘when person showing distress and agitation staff are to try distraction techniques i.e. talking to [Person] in a calm voice’ and ‘ask [Person] if they would like to sit in a calmer environment and give [Person] their PRN (as required) medication if [Person] shows aggression or agitation.’ The reviews do not consider the primary need or trigger for the person’s agitation and frustration and how the person could be supported in a more effective and positive way to prevent or reduce their agitation and frustration.

We noted on all 3 visits to the service that people were not occupied with any meaningful occupation, which would help to reduce agitation and frustration. Both lounges were noisy from loud music from the television. People with dementia often experience increased sensitivity to noise, which can significantly impact their quality of life and increase confusion, stress and agitation which can lead to anxiety and behaviours. There was no indication that people liked the music or wanted the TV on as non were engaged in watching.

Staff told us that lessons learned were shared during morning meetings called ‘Flash’ meetings. A flash meeting was a brief gathering with staff, led by the senior, that facilitated information giving and instruction for each day. Records of flash meetings were brief and did not reflect any incidents or learning from an incident or how to achieve an expected outcome to support staff understanding, and influence change in practice. For example, lessons learned recorded on flash meeting record for 18 October 2025 stated, ‘Focus on person centred care and promote independence for all residents.’ Whilst external consultants initially provided an overview and monthly summary and analysis of accidents and incidents, there was no evidence to show their recommendations and lessons to be learned had been carried forward. For example, in April they stated for lessons learned that ‘Early signs of disorientation and restlessness must prompt earlier interventions.’

The provider did not work well with people and healthcare 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.

At our previous assessment Quenby Rest Home was part of the Recovery to Home (RTH) project that provided reablement care and support to people discharged from hospital, with the aim of supporting people to return home. The service did not maintain safe systems of care and people were not always safely and effectively supported on the reablement pathway. Following our assessment the project was terminated, and Commissioners placed an embargo on admitting new people to the service. Whilst there had been no admissions staff shared they were not involved in the process. Staff were unable to tell us about a formal admission process in place that would ensure they had the relevant information available to them to meet new people’s needs. One staff member told us, “Management deal with new admissions, we ask the person how they would like things done and then we tell management. If they can’t tell us, we look at the handover sheet or ask the senior.” This showed the provider had not put in place a safe process for the safe transition of a person to the service, and the service was not prepared to take new admissions.

The service failed to keep relatives involved and updated with information about their family member during transitions to and from hospital. One relative told us, “I did get a call recently to say that my [Person] had had a bad fall and was in hospital, having surgery as a result. I wasn’t told how it had happened, and I haven’t heard anything since. I found the number of the hospital they were in and had to track them down. I found out they had fractured their femur.” Another relative said, “We ring for feedback or updates on what is happening with [Person], and it was a job finding them when they went into hospital. Took me ages to track [Person] down.”

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.

Our last assessment found 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. Management was not effectively investigating safeguarding concerns or documenting their findings, actions and improvements made because of a safeguarding concern. This assessment found the provider did not recognise or understand the wider aspects of safeguarding people from risk of avoidable harm as identified in this report. People who expressed their frustration and anxieties through their behaviours were not effectively supported. Positive actions were not planned for or put into practice when staff were faced with difficult situations that could potentially compromise safety. Staff spoken with were unable to explain any positive actions in place for people to prevent or reduce their frustration and anxieties. Staff had a limited understanding of how dementia affected people in their day to day living. Appropriate strategies were not in place and staff did not know how to promote and keep for as long as possible, individual's interests and independence, and keep them safe.

Staff had received safeguarding training, but not all demonstrated a good understanding of it or how to report any concerns to the local authority, the lead partner in safeguarding. When asked what safeguarding meant to them one staff member said, “You ensure residents have a good quality of life, if anything challenges it, we have to safeguard, like food if they insist on having it, if a person hurts themselves or others you have to safeguard.” When asked what they would do they said they would report to their senior and if it continued, they would go up the chain to the head of care and then the manager.”

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. Our last assessment identified significant failings in relation to managing risks to people from choking. People with dementia, Parkinson’s Disease and strokes are more susceptible to dysphagia (difficulty in swallowing) resulting in an increased risk of choking. Those at risk are prescribed varying textures and consistencies of food and drink in line with IDDSI (International Dysphagia Diet Standardisation Initiative) standardised diets, to reduce their risk of choking. This assessment found the provider’s risk management arrangements remained insufficient to ensure people’s safety from risk of choking. A person’s diet care plan showed their IDDSI food texture level had changed from a level 7 (easy to chew) to a level 4 (pureed) and fluids to a level 3 (moderately thick). However, all their associated care plans were inconsistent and did not reflect the correct IDDSI texture level. This had not been identified and could cause confusion for staff and put the person at risk of unsafe care.

Whilst staff, following our last assessment, had received training in Dysphagia and IDDSI we found a new cook had been recruited in July 2025. They had not received training related to preparation of special diets or IDDSI standardized texture diets prior to or during the 2 months since their employment began at the service. We raised this immediately with the manager and they have since received the training. Effective equipment had not been provided to the kitchen to prepare pureed meals for people. A blender was purchased but this only lasted a week and requests for a replacement was not forthcoming and so the cook brought in their own. We raised this immediately with the manager and a replacement was purchased.

Observations of staff moving and assisting people to transfer from chair to chair showed poor practice, placing people at risk of falling or injury. Risk assessments and associated moving and transferring care plans lacked personalised detail to inform staff the extent of the person’s ability to support their own weight and any other relevant factors such as pain, fatigue, stiffness etc which they should be aware to assist a safe move. Review of people’s moving and transferring care plan and falls risk assessment contained no guidance or intervention from the falls team to inform staff on how to safely support them to stand up.

Risk assessments undertaken for the use of bed rails did not demonstrate if alternative safety methods had been considered and what those methods were. Capacity assessments for the use of bed rails did not consider the safety elements for a person who lacked capacity. One relative told us, “I got a call from the office to tell me [Person] had been found trying to get out of bed and had got their feet over the bedrail. I don’t think they hurt themself though and I’m not sure if anything changed after that.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care.Our last assessment found the provider was not protecting people from risks in the care environment. This assessment found significant risk relating to fire safety. A fire safety risk assessment carried out in July 2025 by an external fire safety consultant found the risk to life at Quenby Rest Home was ‘Substantial’. The fire risk assessment action plan set out immediate actions to reduce the risk to life in the event of a fire. These actions were prioritised according to the nature of the hazard and the severity of the risk. Our visit on 23 September 2025 found the provider did not have a suitable plan in place that demonstrated the action needed and the urgency proportionate to the risk to life. Fire protection measures and high priority actions advised in the fire safety risk assessment remained outstanding. The Commission took urgent enforcement action to mitigate the risk and improve fire safety arrangements.

A legionella risk assessment was carried out by external contractor on 19 May 2025 to establish risk of Legionella bacteria in the domestic hot and cold-water systems. The provider had not carried out the urgent actions required within the given timeframes to mitigate potential risks that are more likely to cause harm in the long term. The premises remained hazardous in places and were not suitable to meet people's needs. A large electric fly killer was positioned on the draining board of the sink unit in the kitchenette area of the bottom lounge. This placed people at risk of harm if touched of a possible electric shock or burn. After raising this concern, we noted the unit had been removed. However, there was another located on the wall of the smaller dining room area, but the electric cable remained trailing to the socket below causing a further risk if pulled. A stand-alone portable radiator had been positioned in the bottom lounge which was very hot to touch posing a potential risk of harm to people from falling over it or burning from touching it. The radiator has since been removed.

The larger lounge was cluttered with items stored there and the garden was not accessible to people with mobility needs; there were no clear pathways and purposeful areas. Feedback from relatives clearly showed that the garden was an important part of many people’s lives. The provider had not considered how they could ensure outside green space supported individuals social, mobility and sensory needs and promoted wellbeing. One relative told us “If they could open up the bottom lounge a bit more easily to access the garden, that would be great for residents” and “Some paving to access the raised beds in the garden would be good.” During our visit on 15 September 2025, 4 people told us they were cold. People had refused showers because it was too cold. We found the heating thermostat had not activated the central heating. Neither the deputy manager nor staff knew how to override the system to ensure the heating came on and had to contact the former maintenance person for instructions.

A refurbishment programme had commenced; areas of the home had been or were in the process of re-decoration. Whilst people had been given a choice of colour for their bedrooms, a dementia friendly design for the home in line with best practice guidance had not been considered to provide an enabling environment. Such as quiet areas, lighting, orientation, lay out of chairs, safety, points of interest and clear signage. Relative’s comments included: “I did notice some decorating, improvements and upgrading was going on when I last visited which is very welcome and probably a bit overdue,” and “It’s good to see there is some maintenance going on at last. The owners have often promised decoration and upgrading over the years.”

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 provider did not have a clear overview of the complexity of people's current needs and levels of dependency. Whilst the manager and care director told us the occupancy had reduced but the staffing numbers remained the same, staff were not deployed effectively to always respond to people’s needs. The tool used to inform the providers decision on staffing numbers did not take account of people's personalised needs and risk including social, emotional or dementia related needs. They therefore did not reflect dependency levels accurately. Relatives told us there were not always enough staff about. One relative said, “I have seen a staff member in 1 lounge asking another staff member from the other to come through and help take someone to the bathroom, they needed 2 carers, which means sometimes people needing the toilet have to wait.” Another relative said, “I have noticed when visiting and sitting in the lounge, that sometimes residents who need the toilet have to wait a while and some can become agitated.”

Staff told us their workload was not always manageable. Whilst they had fewer people using the service, people’s needs had increased requiring higher levels of care with support to use toilets, hoisting, and repositioning. Six of the 14 people required the support of 2 staff for safe moving and handling. One member of staff commented, “[Person’s] care plan states they need [to use the toilet] and repositioning every 2 hours, we try our best.” Staff told us, due to the increased level of people’s needs; they had not been getting their breaks. Suggestions put forward by staff in August 2025 were to provide staff with walkie talkies so they could summons assistance. This indicated deployment of staff was poor, and in the event a person required the assistance of 2 staff, the lounges would be left unsupervised, and people would be at risk of harm. Incident records identified unwitnessed falls each month, however root causes had not been explored such as reviewing staffing numbers and deployment. One person had fallen while trying to get out of the front door. The incident was recorded as an unwitnessed fall but there was no record to show the incident had been thoroughly investigated to ascertain the circumstances leading up to the person being able to get to the front door unnoticed. The front door is located at the furthest end of the service, quite a distance from the communal areas.

Since our last assessment staff had received basic training in dementia awareness but little work had been done regarding a more substantive training for staff to develop their knowledge and understanding, increase their skills and equip them to support people with dementia more effectively. Staff had completed eLearning, but skills were lacking in person centred care, engaging with people in purposeful activity and responding effectively to the wider aspects of dementia related needs, including communication and unsettled behaviours.

Recruitment processes were poor. References were not always sought from last employer and some only had character references from friends. Interview records did not demonstrate values, understanding and experience was fully explored to identify learning gaps and suitability for the role, as employment history was not always relevant to the stated purpose of the service. Inductions were operationally focused and a long checklist. They did not focus on fundamental areas as outlined in the Care Certificate standards. The Care Certificate is a set of 16 standards for Health and Social care support workers covering essential knowledge, skills and behaviours for providing safe high-quality care.

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.Our previous assessment found 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. This assessment found improvements had been made. However, further attention was needed to ensure the facilities were suitable and enabled effective cleaning. Where a new stainless-steel sink had been installed, plaster, cement and glue remained on the wall where an old sink had been removed, which meant the wall did not have a flush impermeable surface. Where soap dispensers had been moved, holes in tiling had not been filled in. There were missing tiles above the sink in the cleaner’s cupboard. Cracks, fissures, holes, and rough or uneven surfaces create niches where dirt, moisture, and organic matter can accumulate. These areas are difficult to clean effectively with standard procedures and products, making them potential breeding grounds for bacteria.

Further work was needed to ensure food was being stored in line with food safety standards, and hygienically. The food store in the outbuilding had ripped and damaged flooring. The ceiling was in poor condition, with holes in places, some of which had been patched up. The upright freezer had a collapsed shelf and needed defrosting. This increased the risk of food spoilage and foodborne illness, as the excessive frost prevents the freezer from maintaining a consistent, cold temperature of – 18 degrees.

The infection control policy had been updated to include the most up to date relevant national guidance to support staff to safely deliver care in relation to IPC (Infection prevention and control). The local authority integrated care board ICB (Integrated Care Board) IPC team shared their findings with us following their follow up audit of Quenby Rest Home in July 2025. This showed there had been significant improvement in the cleanliness and hygiene of the service since their previous audit in March 2025. We found the premises were noticeably cleaner. One member of staff commented, “The changed working pattern and increased numbers of housekeeping staff has made a difference and helped to improve cleaning, including doing deep cleans.”

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. Systems were in place to safely store, give and record administration of medicines. Medicines administration was being recorded on medicine administration record (MAR) charts. There were no gaps in recording which meant people were receiving their medicines. People’s allergies were documented but we found two occasions where the documentation was conflicting, and allergies were missing. Staff ensured people’s consent was given and their preferences for how they wanted their medicines administered was respected. One person was very sleepy, and the carer was concerned that the person was at risk of choking so postponed the administration of the medicines. Some medicines recommended to be administered separately were being recorded as given at the same time as other medicines although when we spoke to staff they had been given appropriately. It was unclear from 1 person’s documentation whether Parkinson’s medicines were being given at the correct time. It is important that these medicines are given on time to optimise the control of symptoms.

For medicines that could be given when required, there was a current protocol in place to assist staff, but some lacked detail. For example, we saw a protocol for morphine that did not specify anything more than ‘pain’, with no details as to when it would be appropriate to administer morphine or for what type of pain. We saw administration of sedative medicines to control people’s behaviour was a last resort and we only found 1 occasion when it had been used, and this was appropriate to keep the person safe. Controlled drugs were stored, recorded and checked appropriately. Some of the tablet crushers found were not clean and contained tablet residue, this was actioned immediately by the provider. The administration records and care plans completed by district nurses for insulin were clear and available to care staff. Carers were trained to be able to respond to episodes of hypoglycemia (low blood glucose).

Medicines administered by a topical patch were recorded but sometimes the site of application was not rotated in line with the manufacturer’s instructions. Body maps were in place to help carers administer topical creams and ointments to the correct areas and we could see these were mostly being followed. Most care plans were in place for medicines including people on anticoagulants and were of sufficient detail to allow staff to make appropriate decisions. There was 1 care plan missing for a person receiving an antiepileptic medicine. One person was having their pulse taken before the administration of a heart medicine, but care plans did not specify what pulse reading would warrant omitting the medicine. Staff were trained in medicines administration and had completed competencies. Incidents were being reported and investigated. Medication audits were being completed, and actions had been taken to address any issues.