The Chase

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 the legal regulations in relation to people’s safe care and treatment, the way people’s medicines were managed safely, risks relating to the environment, safe and effective staffing and 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.

The service had a poor history of sustaining quality care to ensure people received safe care and treatment. The provider’s oversight of the service was poor; audits and checks did not identify any of the significant concerns we found at this inspection which left people at risk of harm.

People’s daily notes and records were inadequate, lacked important information and were not always factual. The registered manager had told staff at a staff meeting in May 2025 that reports did not contain enough information to understand what people did each day. Another staff member raised concerns that when reading daily reports, they did not match reports made by outside agencies. No action had been taken to improve this, and we found daily reports continued to lack any meaningful detail to understand people’s experiences. When peoplebecame distressed records lacked any detail about action staff took in response to support the person or learn from incidents so repeated events could be minimised.

There was no clear learning culture in the service, there were no structured debriefs after any incidents in the service. When areas of improvement were identified there was no follow up or evidence of improved outcomes.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. The provider 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. They did not assess, manage or monitor people’s safety effectively.

The registered manager told us the assessment process needed to improve, particularly for people who were discharged from hospital, and there were times when people moved into the service and their behaviour and needs did not match what staff had expected. The registered manager said, “Assessment can be hard if not given right info, you’re reliant on family, friends, hospital and you may get an hour. With (person) what we were told was very different from what we observed. Going forward we will be more choosy about who we take because some of the settling takes a while. Sometimes you're lucky.” However, there was no clear plan for how they proposed to improve the transition process. People’s needs were not assessed in a holistic manner. There was no established system for monitoring or assessing health risks which could cause people significant harm. Some care plans contained no information about people’s specific health needs such as the monitoring of wounds or the management of constipation.

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.

People were not safeguarded from inappropriate care and treatment. Staff had poor guidance and understanding of how to support people with distressed behaviours. Care plans lacked any specific guidance or risk assessment about how staff should support people when they became distressed. Medicine to sedate people when they were distressed was administered without a clear plan or as a last resort.

Some of the staff we spoke with had a poor understanding of safeguarding people. They could not describe how to recognise neglect or abuse or who to escalate any concerns to outside of the service. Some staff lacked knowledge in safeguarding people from potential harm. For example, 1 person was cared for in bed. There was a lack of understanding around how staff would safely support the person to evacuate in an emergency.

The providers approach to learning from safeguarding incidents was not robust. The registered manager said, “If something happened for example the recent safeguarding we spoke with staff about it. We discuss it at the very least between me, the deputy and the head of care. Then we feedback to staff.” There was no recorded information about which staff this was discussed with or what had been learnt or implemented to improve outcomes for people.

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 and supportive. We identified risks in relation to the safe management of pressure wounds, constipation and diabetes. People’s health needs were not well documented to understand escalating risks for example, when people’s wounds had deteriorated.

Some people were at risk of constipation. Guidance around managing constipation risks was either missing or not detailed or robust. There was no information about what staff should do if a person became constipated or how this should be monitored or responded to. We were not assured staff had the skills to be able to deal with any constipation concerns safely. Although some bowel monitoring records were in place for some people, we found multiple days where no bowel movement had been recorded and there had been no further follow up to ensure the person was not constipated. The registered manager was unable to provide any assurances people were not constipated or this was well managed.

Some people had wounds but there were no care plans or risk assessments in place to monitor deterioration or to provide guidance to staff so they could support people safely. There was a complete reliance on external professionals such as district nurses to manage this. The registered manager repeatedly told us the service was not a nursing home, and they were not responsible for the management of people’s wounds as they were not medically qualified. They failed to understand their responsibilities around the management and support of people with wounds and the prevention and monitoring of this to ensure people were safely supported and concerns escalated in a timely and consistent manner.

Although there was guidance in place around the management of diabetes the staff we spoke to had a poor understanding of the signs and symptoms to look out for should a person become unwell. Guidance made no reference to foot care and the risks associated with this which can have a detrimental impact on people with diabetes if it is not monitored and supported well.

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. Some areas of the environment needed improvement.

Audits and the maintenance schedule had not identified some of the areas of concern we had. We found an unlocked storage cupboard containing bedding. There was a tray in the cupboard containing Epimax creams, razor blades and alcohol hand gel. People would sometimes pick things up that did not belong to them so this could pose a potential risk to their safety. We observed items in people’s rooms which the registered manager told us did not belong to them and should not be there. A lock was fitted to the cupboard following the inspection. There was a steep step next to the kitchen which could be a potential trip hazard. The boiler cupboard on the ground floor was unlocked which posed a potential burns risk. There was a wooden ramp on the outside of the building that was rotten and a trip hazard. When stepped on, the surface gave way and started to break up which posed a risk to the people living at the service.

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 registered manager provided information about competency checks on staff but there was no information about what areas they specifically checked staff were competent in, or who was checking those competencies. There were no assurances staff that checked the competency of other staff had the right skills and knowledge to do this. For example, we asked the registered manager for more information around the training staff completed in regard to manual handling, first aid and choking. They told us this was completed online then followed up with a workshop led by the head of care with questions and answers and a demonstration on equipment use, followed by competency checks. No evidence was provided about the head of care’s qualification to do this, evidence of which staff this related to, or when it occurred.

Staff were not recruited safely. Records showed some staff references were from their friends rather than previous employers, identification and right to works checks were out of date, and DBS checks were stated as having been competed but there was no evidence of the result of the checks or if staff were suitable to work with people. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with vulnerable adults, to help employers make safer recruitment decisions. We have found issues around the safe recruitment of staff at previous inspections.

The provider did not make sure that medicines and treatments were safe. Medicines were poorly managed and audited.

One person was prescribed ‘when required’ (PRN) medicines for the management of behaviours due to incidents of distress. There was no PRN protocol or guidance for staff to instruct them when this medicine should be administered. It was not clear why the person was given the PRN which had a sedative effect at particular times. We reported our concerns back to the registered manager who was not able to provide any assurance as to why staff gave this medicine at certain times. The PRN was prescribed as once a day when required but more than 1 tablet was given on occasions. The person’s care plan identified they were at risk of falls and lacked hazard awareness. Medicines with sedative effects are known to increase risk of falls, and their risk assessment did not reflect this was an additional risk staff should be aware of. This put the person at risk of avoidable harm and being unnecessarily sedated via chemical restraint without appropriate support, safeguarding and monitoring measures in place. There were no outcomes documented when PRN was administered so the impact on the person was unknown. There was no information about how other steps should be taken so chemical restraint was a last resort.

A medicine audit conducted in June 2025 identified 2 people had refused their medicine but provided no information about what action was taken in response to manage the risk this posed to people.

We checked medicines and found discrepancies in stocks which had not been identified through the provider’s audits. Records around medicines were poor, and it was unclear when people received their medicines as some records were signed in advance. There were some gaps in records, so it was not clear if medicines had been administered or not. One person had a medicated patch to relieve pain which should be rotated on the body each time a new one is applied. There were no body maps in use to document where the patch was administered. Should the patch fall off, staff would not know where they should safely apply the next patch.