Hallmark Angmering Grange Luxury Care 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. This is the first assessment for this newly registered service. This key question has been rated Requires Improvement. This meant some aspects of the service were not always safe. There was an increased risk that people could be harmed.

The service was in breach of legal regulation for governance at the service regarding ineffective oversight and support around staffing.

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 report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had policies and processes in place for staff to report near misses, accidents and incidents, including any concerns they had about staff practices. However, these processes were not always followed or effective. For example, we viewed staff files which evidenced some incidents and near misses involving people using the service had occurred. However, these events had not been recorded on the provider’s electronic system for leaders to investigate, take appropriate actions and share with external agencies as required. This meant opportunities for learning and to reduce future risks were missed. Leaders had not been aware of these issues identified during this assessment.

The majority of staff we spoke to expressed concerns about the culture of leaders. They told us there was a “blame culture” at the service when things went wrong. Staff comments included, “In the beginning, they told us they don’t have blame and shame but soon after I started working here, I realised it’s not like that. [Leaders] like to point the finger” and “I have heard team members discussing events and how it was not always done in a supportive way. This is discouraging as it does not help in any way to educate or support staff in what should be done.” Staff told us they had raised concerns about certain staff members’ practices or lack of experience, skills or confidence to do their role safely and effectively. Staff felt no improvements had been made. They told us this negatively impacted morale and did not always promote a positive learning culture. The provider completed a staff survey in 2024 and developed an action plan following concerns about staff morale. However, the staff survey completed in 2025 continued to highlight similar concerns. This indicated that actions taken had not always been effective in addressing the root cause of low morale or ensuring learning and improvements were embedded.

The provider had an action plan in place to address the culture of the organisation. This included introducing a Human Resources (HR) clinic for staff to raise concerns and additional training and coaching for leaders. However, the provider’s action plan had not identified all of the issues found during the assessment. The provider has since taken additional actions to address the areas highlighted. This will take time to embed in practice.

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.

Leaders completed pre-assessments prior to admitting people to the service. Care plans were completed which ensured their needs could be met. Where people required specialised support, staff referred them to the appropriate health and social care professionals. A staff member said, “We refer pressure wounds to the Tissue Viability Nurses (TVN) and inform the GP. We follow TVN wound care management plans. Repositioning plans are put in place, and we reinforce to staff how this is important. Nutrition care plans are important to heal the wounds as well. When it's healed, it's very rewarding.” A healthcare professional said, “I believe the teams within the homes do act in a timely way and take appropriate actions when needed. Staff have acted on what has been suggested.”

The provider did not always work effectively with people and healthcare partners to fully understand what being safe meant to them and how this should be achieved. Systems and processes were not always consistently applied to demonstrate the provider was continually improving people’s lives and protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were not always shared with relevant partners in a timely or appropriate way.

People appeared comfortable with staff. Relatives told us they felt their loved ones were safe. Comments included, “Safety is important and my loved one is my priority. I feel comfortable with the support the staff provide” and “I feel my loved one is safe.”

Staff had received safeguarding training and understood how to report safety events. However, they told us incidents and near misses were not always recorded or reported because they did not always have enough time to do so. We identified some incidents and near misses for people were documented in staff files for performance management of certain staff. However, these events had not been recorded on the provider’s electronic system where people were at risk of harm or neglect. The providers systems and processes had not identified our findings during this assessment. The specific events identified during this assessment were subsequently investigated and appropriate actions taken. Although no people had been harmed, providers should have effective processes in place to ensure people are not at risk of avoidable harm. Although the provider already had an action plan in place, they had not identified all of the issues we found during this assessment. They have subsequently taken further actions to address this. However, this will take time to embed.

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). Where required, people had DoLS in place or applied for. Staff supported people in the least restrictive way.

The provider had systems and processes in place to support people to manage risks. However, these were not always effective, as staff did not consistently provide care that was safe, supportive and enabled people to do the things that mattered to them

Care plans contained guidance for staff on how best to support people. The provider had tools and processes in place to monitor risks for people. Most staff understood about risks people had such as choking, dehydration or pressure wounds. However, some records we viewed demonstrated inconsistencies in the actual support people received for personal care and repositioning. For example, 2 people had not received repositioning support in a timely manner which resulted in them developing red marks. This had not been recorded in their care notes, reported or investigated. Although no harm came to them, it highlighted an area for improvement in how some staff supported people to manage risks to their health. While the provider had an action plan in place, it had not identified all of the issues found during the assessment. The provider has since taken additional actions to address the areas highlighted. However, this will take time to embed.

People and relatives told us they were consulted about their views, and care plans reflected individual preferences. A relative said, “[Person] isn’t keen on the hoist. Transfers are variable, sometimes staff use the hoist or sara steady equipment. [Person] is aware that the staff know what they are doing and feel safe. They just do not like the sensation of being hoisted as they have no control. Staff talk it through with [person] who is able to make their own decisions.”

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

People had access to the equipment they needed to stay safe.We observed staff using equipment and supporting people to move throughout the building safely.People had personal emergency evacuation plans in the event of a fire. Staff received fire training and participated in fire drills. The provider had recently received their fire safety risk assessment and plans were in place to address actions. Systems were in place to ensure routine maintenance and servicing took place and equipment was safe to use. The environment was clear of clutter and risk assessments had been completed.

The provider did not always make sure there were enough staff or effective deployment to ensure they had the right skills and experience to support people safely. Leaders did not always make sure staff received effective support and supervision. They did not always work together well to provide safe care that met people’s individual needs.

People and their relatives told us they were happy with the staff at the service. However, people told us that it could be short staffed at times. People told us, “It was implied by staff if I was an early bird then I would have been sorted by now” and "There are not enough staff all the time. Sometimes I think there could be more. If I need someone, I will go and look for them." We received mixed feedback from relatives. Comments included, “There is plenty of staff on duty” and “There is not always staff around when I visit and I feel I have to be my loved one’s voice. My criticism is there doesn’t seem to be any continuity.”

The provider did not always ensure the service had the right number of staff or effective deployment across teams. This meant staff often focused on completing tasks rather than the quality of care delivered to people. Staff told us “We are quite short staffed. We run around like headless chickens. People have long waits as we need to prioritise who we support first” and “I do not think anyone is being negligent, but the care is rushed and we don't have any quality time to spend with people.” This meant people did not always receive timely support and opportunities for meaningful interaction with staff were reduced. Staff told us they understood there were wider pressures around recruitment. However, they felt some staffing shortages were due to poor oversight and management of the rota. For example, one staff member said, “Allocations and shift cover is very last minute. There are many mistakes such as people on holiday and even people who have left the service are still on there.” Records we reviewed, including staff rotas, daily allocation sheets and staff signing in sheets, did not always demonstrate consistent staffing levels or effective deployment of staff.

Leaders also provided conflicting information about how staffing levels were calculated. One leader told us staffing was provided at a ratio of 1 staff member to 4 people and some records supported this. However, other leaders and the provider told us staffing was calculated based on people’s dependency needs. This meant systems for determining and monitoring staffing levels were not consistently understood or applied by leaders.

The provider had a safe recruitment process which included checks such as references, right to work and criminal records. New staff had to complete an induction, training and shadowing of experienced staff. However, this was not always consistent or supportive. A staff member said, “New carers are originally put on the floor as supernumerary, but they end up being counted on shift. New staff to care are not supported.” We viewed staff files and not all induction records had been completed to accurately reflect staff competence, progress or additional support required. Leaders provided assurances regarding the induction records we viewed. However, they did not always have effective oversight to ensure staff were fully supported and competent to do their role.

Staff told us they had raised concerns about the practice of certain staff members but had not seen clear improvements. One staff member said, “I feel like Human Resources (HR) need to step in as management inside the building can't deal with it all. Policies need to be followed.” Staff files showed concerns had been recorded in line with the provider’s policies and processes. However, these were not always fully investigated, and actions or outcomes were not consistently documented. This meant it was not always clear how concerns about staff practice had been addressed.

Feedback from staff about the support they received from leaders was not always positive. Many staff told us the supervision and appraisal process was not supportive. One staff member said “I have supervisions. You receive the form and fill it in. You don't meet them.” We reviewed supervision and appraisal records and found some were blank, incomplete or missing. Records did not always demonstrate that leaders had provided support or followed up on issues raised by staff. This meant the provider did not always have clear oversight of staff support and development.

Although the provider already had an action plan in place, this had not identified all of the issues we found during this assessment. They have subsequently taken further actions to address this. We identified a breach of regulation for governance in relation to ineffective leadership, oversight and support to ensure consistently safe and effective staffing. We will check for sustained improvement at our next assessment.

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.

People told us staff used personal protective equipment (PPE).Staff had a good understanding of infection, prevention and control (IPC) and had received training. There was enough PPE available throughout the service. Sluice rooms were clean and safely locked. A sluice room is used to dispose human waste and soiled items safely and prevents the spread of infections within a service. The service had an IPC lead. They said, “No outbreaks yet. Last year, there was an outbreak of respiratory infections. We increased hand hygiene hand checks, residents isolated where they could and we recommend PPE to relatives.” The provider had effective processes and policies in place to minimise the spread of infections.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they had received their medicines safely. Comments included, “It’s given to me when it’s meant to be” and “I know what medication I take but the staff here give it to me which I prefer. I will take the medication they give, sometimes I ask and they tell me what it is for.” A relative said, “Medication is administered by the staff. If we take [person] out, the staff always ensure that the medication has been taken and inform us when the medication is due so we can work together around it.” Another relative said, “When [person] first moved into the home, they were sleeping a lot. The senior discussed a medication review with the GP which resulted in the medication being reduced, which is far better as my loved one is a lot more alert.” We observed medicine support being delivered in a person-centred way. Staff had received medicines training and competencies were carried out to check their knowledge and skills. Medication was stored appropriately with temperature checks taking place and staff used safe disposal practises for medication that was no longer needed.