Divine Care Centre

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 management oversight of how people’s medicines were managed.

This service scored 59 (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.

Learning was not always effective due to the provider’s lack of robust systems. This had resulted in a failure to identify and record safety concerns

Since starting in post, the registered manager had begun to strengthen the service’s learning culture. New systems had recently been introduced to ensure information about incidents was used to improve practice and enhance outcomes for people. A retrospective accident and incident log had been completed using electronic records, and any new incidents were now routinely logged and analysed through monthly audits to identify trends and risks.

Lessons learned were now being recorded on all incident forms and were shared through daily ‘flash meetings’. These had been introduced in April to promote open discussion and continuous improvement but more time was needed to ensure they were fully embedded. A member of staff told us, “Within [the electronic record system] all accidents and incidents are reported and lessons learned are shared with staff at the daily flash meeting and cascaded to all.”

Evidence of effective learning included appropriate referrals to the falls team after analysis of incidents highlighted concerns. This resulted in the implementation of a care plan and specialist equipment to reduce risk.

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. Pre-admission assessments were completed and people’s needs were also reviewed when being discharged from a stay in hospital.

A closed-circuit television (CCTV) system was in use in communal areas of the home to help keep people safe whilst also respecting their privacy in personal spaces. This was managed appropriately and in line with best practice.

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.

Safeguarding concerns had not always been shared appropriately. The provider had recognised that concerns were not always escalated correctly. A quality compliance manager and an area manager had been tasked with submitting retrospective alerts to the local authority. Since starting in post, the registered manager had begun to strengthen safeguarding systems and the most recent concerns had all been shared in line with best practice. More time was needed to ensure new systems had been fully adopted into working practice.

Staff completed safeguarding training and the staff we spoke to knew how to recognise and report safeguarding concerns.

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). People who were subject to DoLS were appropriately cared for. DoLS applications were made when required and the service followed the safeguards that were put in place.

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 care plans and risk assessments were in place, they were not always sufficiently robust to identify and manage known risks. The registered manager had already begun to take action to improve these records prior to our assessment, but systems were not consistently effective at the time of the inspection.

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

Safety equipment such as window restrictors and emergency pull cords were in place but did not comply with current health and safety guidance. Action was taken following our feedback and we received confirmation that all necessary changes were made by 22 June 2026

There was a lot of unused equipment stored around the home restricting people’s ability to safely access some communal areas. Some items had been stored in stairwells which posed a fire hazard. We discussed this with the registered manager who took prompt action and when we returned for our second day of inspection most of the items had been moved and a plan put in place for the remaining items to be collected.

Fire drills had taken place, but comprehensive records had not been completed. Following our feedback additional drills took place. Records from recent drills were much improved but this good practice needs to be embedded to ensure management have good oversight of how staff would respond in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff were recruited safely with the appropriate pre-employment checks undertaken. A member of staff told us, “There are generally sufficient staff on duty to meet residents' needs safely and effectively.”

Although there had been some gaps in training when the registered manager came into post, they had recognised this and taken action. They had encouraged staff to complete any outstanding training and also sourced specialist training to ensure staff had the necessary skills to meet people’s needs. People and their relatives felt staff had the knowledge required to support them safely and we received positive feedback about staff from external health professionals. One professional told us, “Staff and carers are generally knowledgeable about residents, contributing effectively to discussions and supporting collaborative decision-making.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. A professional told us, “We have been into visit a resident with an infection. All aspects of care were appropriate, and the resident was well managed.”

Appropriate infection prevention and control (IPC) procedures and policies were in place. Staff had received training and were observed using personal protective equipment (PPE) appropriately. The service was clean and tidy and the housekeeping staff were knowledgeable and efficient. Some areas of the home required updating and redecoration and this meant effective deep cleaning was not always possible, for example areas where paintwork was chipped or damaged could not be effectively cleaned and some flooring was stained. The management team had already identified this. Some updates had already been made, and an improvement plan was in place to make further improvements.

The home had scored highly in the most recent external IPC audit. The specialist team who conducted these had found only minor concerns which were addressed immediately.

The provider did not always make sure that medicines were managed safely as clear and consistent records were not always kept. Stock balances of medicines were not always recorded and when recorded did not always balance with records.

Care plans were not always updated to accurately reflect currently prescribed medicines, although some care plans for patients with complex medical needs were sufficiently detailed.

Guidance for the administration of “as required” medicines or those with a variable dose was sometimes missing or lacked sufficient detail to enable staff to decide what dose to give.

Where thickeners were prescribed to make drinks safer for those people at risk of choking, records were not always completed to demonstrate that this had been used as directed. The safe storage of thickener was not well managed on the first day of our inspection but this improved following our feedback.

Records were not fully complete for creams applied by care staff. There was a noticeable improvement in recent records, although there were still some gaps regarding the type of cream applied, or the body area it was applied to.

Patch application records weren’t completed to indicate that application sites were being rotated in line with manufacturers’ guidance. A new system was implemented during our inspection.

Medicines storage rooms were clean, tidy and well-organised. Storage and record-keeping for controlled drugs was good. Temperature monitoring was in place and completed appropriately.

The newly registered manager was aware of some of the issues relating to the management of medicines and was taking steps to implement improved practices.