Tapton Grove

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 people’s safe care and treatment.

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. Whilst leaders listened to concerns about safety, lessons were not learnt to continually identify and embed good practice in a timely manner. Leaders did not effectively foster a culture of learning from safety concerns or incidents. As a result, similar concerns continued to arise, and people remained at avoidable risk of harm.For example, we found hazardous substances such as bleach and cleaning products stored unsafely under the kitchen sink, in breach of Control of Substances Hazardous to Health(COSHH) regulations. Staff told us they had raised this concern with leaders previously, but no action had been taken until our regulatory intervention. We identified unsafe food storage practices, including a fridge operating at 12°C, significantly above the recommended safe temperature. The provider assured us this had been addressed, but on our second site visit, we found the same fridge was still not working properly, and food was once again being stored unsafely, including items that were out of date. These risks had not been effectively monitored or resolved.We also found faulty window fittings in multiple bedrooms, which posed a risk of serious injury. Although leaders told us they were aware of this issue, they had not acted to fully understand or mitigate the risk until prompted by our assessment. Leaders did not respond effectively to concerns raised by the Local Authority commissioners over 7 months prior to the inspection. These concerns remained unresolved at the time of our assessment and reflected wider failings in the service’s learning culture.These repeated concerns, and the delays in addressing them, showed that learning was not embedded within the service. One staff member told us, “We can raise concerns, but nothing changes.” This lack of a learning culture meant that risks were not reliably identified or reduced, and improvements tended to be reactive and not sustained.

The provider did not consistently work effectively with people or external partners to establish and maintain safe systems of care. Safety was not consistently managed, monitored, or assured, which impacted both the continuity and safety of people’s care, particularly for those with complex needs or placed out of area.People’s progression pathways were unclear. There were no structured plans in place to support people to move on from the service, and some people had been living therefor extended periods without a clear route toward greater independence or transition. Where multidisciplinary teams (MDTs) made recommendations to support recovery, such as through substance misuse screening or interventions, these were not consistently followed. For example, in cases where drug or alcohol testing had been recommended, there was no evidence that this had been arranged or actioned. This lack of follow-through limited people’s progress and undermined opportunities for recovery.There were missed opportunities of joined up working with external professionals, such as advocacy services. Information about risk was not always shared effectively within the service. Staff reported that handovers were often lacking in essential detail and did not equip them with the information needed to deliver safe, informed care. One staff said, “We have hand overs every day and night before the start of every shift but they are not really useful as things never change”. Systems and processes intended to assess, monitor, and improve safety were ineffective. As a result, people were exposed to avoidable risk and did not receive safe or consistent care throughout their care journey.

The provider did not work effectively with people or external partners to understand what being safe meant to them or ensure that they were protected from abuse, neglect, or avoidable harm. As a result, people’s rights to live safely, with dignity and without fear, were compromised. People and staff raised concerns about their safety, including reports of night staff sleeping on duty and failing to respond to alarms, and staff using personal phones, wearing headphones, and speaking in non-English languages in front of people. Such conduct compromised both dignity and safety. There was a safeguarding policy in place and staff received safeguarding training; however, this was not always effectively applied in practice, indicating a limited understanding. Some safeguarding concerns raised by staff to the management were ignored. For example, staff reported people entering the main kitchen unsupervised, despite having limited understanding of the risks and with access to sharp objects such as knives. Leader did not take timely actions until regulatory actions were taken, placing people at potential harm. We observed some people were neglected, and care records showed no personal care had been delivered or attempted over several days. Leaders told us that no safeguarding referrals had been made in response to this. These instances of neglect were not recognised or acted upon by the service prior to our assessment placing people at ongoing risk. Leaders did not always appropriately escalate safeguarding concerns, for example of peer-on-peer altercations. These were missed opportunities to review risks, adjust care plans, or put protective measures in place. Leaders did not appropriately report several recent medication-related incidents as safeguarding concerns, People reported feeling reluctant to raise concerns due to the inconsistency of staff and lack of trust in the service’s ability to act. At the same time, staff reported that they did not always feel listened to, even when raising concerns about people’s safety and welfare. These shortfalls meant the provider did not create or maintain an environment where safeguarding was prioritised.

The provider did not work effectively with people to understand or manage risks to their safety and wellbeing. Care and support were not tailored to enable people to live safely or to engage meaningfully in the things that mattered to them. Risks were not consistently identified, assessed, reviewed, or mitigated, and people were left exposed to avoidable harm.There was no reliable system in place to identify or manage risks. Support plans were overdue for review, and in several cases, key risk documentation was missing. We reviewed 9 care records and found significant and widespread concerns. None included a pre-admission assessment. Current management confirmed these had not been completed under previous leadership (prior to September 2024), and although there had been no new admissions since, the absence of these assessments undermined safe care planning and preparation. We found several examples of inadequate risk management.A person had recently relapsed and was found under the influence of illicit substances a few weeks prior to the inspection. Despite this significant incident, there was no evidence that their support plan or mental health risk assessment had been updated in response. The support plan was already overdue for review since April 2025, and no documented action had been taken to reassess the risks or adjust their care accordingly.Another person with a history of substance misuse was self-administering a high-risk medication, during overnight stays with relatives. No risk assessment had been completed to support this arrangement, and there was no system in place to monitor or manage these periods of leave.One individual had conditions in place from external authorities, due to known safeguarding concerns. Staff told us this person frequently spent time outside alone, but there were no records of their whereabouts or any system in place to monitor their movements. Their care plan did not reflect or manage this known area of risk, nor did it set out how staff should safely support or supervise the person in these circumstances.Another individual with a history of suicidal ideation and ligature attempts had no current risk assessment or Positive Behaviour Support (PBS) plan. Although the multidisciplinary team had recommended weekly drug and alcohol testing, this had not been implemented or recorded in the person’s file.One individual was observed to be experiencing extreme self-neglect. Personal care records showed several multi-day gaps in support. No safeguarding referral had been made, and the person’s care plan contained no assessment of the serious risk posed by their self-neglect.This demonstrated a systemic failure to involve people in managing the risks they faced. Staff did not provide care that was proactive, enabling, or protective. Following our assessment, we requested the provider take immediate action to rectify and mitigate the risks we identified. In response, the provider submitted assurances that the specific risks highlighted during the inspection had been addressed. However, these actions were taken only after regulatory intervention and were therefore reactive in nature.

The provider did not effectively identify and address potential risks in the care environment. There were no effective systems to ensure the facilities and the environment supported the delivery of safe care.We found multiple environmental safety concerns that placed people at risk of harm. On both inspection days, the front door to the service was observed left open, allowing unrestricted access to the premises. Leaders told us that this was not considered a concern, as a staff member was expected to be present in the communal area to observe the entrance. However, during repeated observations, no staff were present, and there was no effective oversight. There was no environmental risk assessment or mitigation plan in place to reduce the risk of unauthorised entry, or the possibility of people subject to DoLS leaving the building unnoticed. This placed people at risk, especially given the vulnerability of people accommodated at the service, including those with complex mental health needs and a history of substance misuse.People were able to enter the main kitchen unsupervised, despite it containing multiple hazards including boiling liquids, hot surfaces, sharp knives, and hazardous cleaning chemicals stored insecurely under the sink in breach of COSHH regulations.We also found that all bedrooms we entered were found to contain heavy wardrobes that were not secured to the wall. These wardrobes were freestanding and could be tipped or pulled over, posing a crushing hazard, particularly to people with a history of distressed behaviour, falls, confusion, or disorientation. Staff we spoke with were unaware of the risk, and there was no evidence that this issue had been identified or mitigated through risk assessment.In addition, we observed faulty secondary-glazed windows in some of the bedrooms. The coil latches designed to keep the lower panes secure were broken, allowing the windows to be lifted and fall suddenly placing people at risk of injury. Staff told us these latches had been broken for approximately three months. Despite this, no remedial action had been taken. Management was aware of the fault but had not recognised the significant risk posed by the falling glass. Furthermore, we observed exposed electrical wiring and overloaded plug sockets in an open cupboard in the board room, containing network and IT equipment. The cupboard doors were left wide open, and a fan was plugged in with cables trailing across the floor. This created trip hazards, increased the risk of fire, and left live equipment accessible. No signage or containment measures were in place to prevent access. Whilst people who used the service had no unsupervised access to the room, it posed a risk to staff. Environmental risks were either unknown, ignored, or poorly understood. This placed people and staff at ongoing and avoidable risk of harm. Following our on-site visit, we requested that the provider take immediate action to rectify and mitigate the risks we identified. In response, the provider submitted assurances that the specific risks highlighted during the inspection had been addressed and we completed a follow up visit and ensured that the risks were mitigated. However, these actions were taken only after regulatory intervention and were therefore reactive in nature.

The provider did not consistently ensure there were enough qualified, skilled, and experienced staff to meet people’s complex individual needs safely and effectively. Staff deployment practices contributed to people’s and staff’s dissatisfaction and challenges in delivering personalised care.Although the home was registered as a nursing home, there was not always a nurse on duty. While this is acceptable if supported by a clear and thorough risk assessment, no such assessment was in place prior to our inspection. One was only developed following our feedback.Staff were frequently moved between different units, a practice that was unpopular with both staff and people using the service. Many staff reported that moving between units prevented them from building trusting relationships and fully understanding the needs of the people they supported. People also expressed frustration at the lack of continuity in care, which impacted their wellbeing. While management stated that rotating staff would eventually allow them to know all residents across the units, this approach faced significant opposition and created instability.High staff turnover and reliance on agency staff to cover shifts contributed to frequent cancellations of activities and disruption to care routines. One staff member said, “ Staffing levels are rarely increased to meet need, and we use quite a large number of agency staff, some regular to the service and some who are not which causes disruption”. Another staff said, “When we are short staffed we can only provide the basic care needs, no activities or meaningful engagement is possible.”Although staff received training relevant to their roles, records and staff feedback indicated that regular supervision and appraisal were not consistently provided. The lack of effective supervision reduced opportunities for staff to reflect on their practice, discuss concerns, or receive guidance and professional development, which could negatively affect the quality and safety of care.Some staff reported they did not feel management treated them fairly and that disciplinary processes were unclear. There was a perception that poor performance was not always managed effectively and that managers were sometimes dismissive of concerns raised. This contributed to low morale and potentially compromised the culture of accountability and learning within the service.Recruitment records reviewed showed that appropriate pre-employment checks, including Disclosure and Barring Service (DBS) checks, were in place. The manager confirmed that recent efforts had been made to address any previous gaps in these checks.

The provider did not adequately assess or manage infection control risks within the service. They failed to identify or respond to key issues, placing people at risk of avoidable harm.We observed several significant infection prevention and control (IPC) concerns. Staff told us people regularly entered the main kitchen without washing their hands and accessed food containers directly, creating a high risk of cross-contamination. Although staff reported these concerns to leaders, no action had been taken.In one unit’s kitchen, we found a fridge storing food at 12°C—well above the safe limit of 5°C. There were no temperature checks or records in place, and the fridge emitted a strong odour. Despite the provider assuring us this would be addressed, our follow-up visit two weeks later found the same fridge still operating above the safe temperature, with food stored inside. Staff did not monitor or record fridge temperatures, putting people at risk of foodborne illness.Food items were not consistently labelled with opening or use-by dates, making it unclear whether they were safe to consume. We found everyday items, such as a loaf of bread had expired by four days but was still accessible to people in the communal kitchen.The premises and equipment were not maintained to a hygienic standard. We observed dust accumulation, sticky surfaces, and rust on radiators and equipment, all of which undermined effective cleaning and increased the risk of infection.Carpets throughout the service were heavily soiled and emitting unpleasant odours. The provider told us they had arranged for replacements. Fixtures such as skirting boards and door frames were scuffed and damaged, which, aside from being visually unappealing, also made effective cleaning and infection prevention more difficult. Although infection control roles and responsibilities were defined, the provider’s implementation did not follow national guidance and failed to protect people from avoidable infection risks.

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 and managing their medicines.Partner agencies shared significant concerns about the provider’s medicines management practices. These included the continued overuse of PRN (pro re nata, or “as needed”) medication in one of the units. This placed people at risk of unnecessary chemical restraint. Agencies also highlighted ongoing medication errors, including with high-risk medicines such as Clozapine, and noted that medication counts remained unreliable. Several recent medication-related incidents had not been appropriately reported as safeguarding concerns or shared with the local authority, indicating a lack of transparency and effective oversight.People were not consistently involved in planning and managing their medicines. For example, we reviewed the care record of one individual whose medication care plan (last updated in June 2025) clearly stated that a risk assessment was required before they could begin self-administering medication. However, no such assessment had been completed. One person regularly took Clozapine off-site during overnight leave, yet there was no risk assessment in place to support or manage this arrangement, despite the known risks associated with this medication.Medication audits were at an early stage of development and had not yet been embedded to support ongoing improvement. The service was unable to demonstrate whether audit processes were effective in identifying and addressing errors or patterns of unsafe practice.PRN protocols, which are essential to guide staff on when, how, and why to administer PRN medication were not adequate. For example, one person had been prescribed both lorazepam and diazepam as PRN options. However, there was no protocol indicating the order in which these should be considered, or the clinical rationale for choosing one over the other. This created a risk of inappropriate or excessive use, especially given the potential for sedation or dependency.Controlled drugs were stored securely, and our sample count during the inspection matched recorded stock. However, record-keeping required improvement to ensure robust documentation in line with legislation and best practice.We observed a medication round during our inspection and did not note any immediate concerns in how staff administered medicines at that time. Staff were knowledgeable about the people they supported and followed basic safety procedures. A clinical staff member informed us that improvements to medicines management had begun under the new management team. However, these systems were still in their infancy, and there was not yet enough evidence to demonstrate that the provider’s approach to medicines was safe, well-led, or aligned with current professional standards and guidance.