Quinnell House

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 the legal regulation in relation to people’s safe care.

This service scored 56 (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.

Peoples’ safety concerns and incidents were not always reported on, there was minimal reflection of how or why an incident occurred, or steps taken to prevent it happening again. For example, one person had had repeated falls and staff had presumed cause but not reflected this in the risk assessment. Information had not been recorded to show how lessons were learned to embed good practices going forward. Staff could tell us examples of how they managed incidents, but outcomes and strategies were not always clearly documented or recorded in risk assessments or care plans. This meant it was not possible to monitor escalations of individual risk, improvements to their health and positive outcomes for people.

Incidents or health events that had occurred had not always been shared with the local authority or CQC

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.

The provider worked well with healthcare partners to establish and maintain safe systems of care; pre-admission assessments were undertaken by a senior member of the team along with information from the placement team or family. Staff told us that they would always undertake an assessment of the person before they arrived at the home to ensure they could meet peoples’ needs. Staff made sure there was continuity of care, when people moved between different services, and ensured all necessary documentation accompanied them. The computer system had a document called a hospital passport that staff could print of that contained all the necessary information about the person.

When people were supported to attend appointments both inside and outside of the service, a passport of their specific needs was printed off and accompanied them.

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. The provider did not always share concerns quickly and appropriately.

Information gathered from health professionals, the local authority and from families indicated that not all incidents and events had been reported to the relevant authorities in a timely way which put people at risk. For example, recurrent falls and sexual inappropriate behaviour. Retrospective reports have now been completed.

Training records showed not all staff had completed recent safeguarding training and when we spoke with staff there were gaps in their knowledge about how to identify and report safeguarding concerns. There was a system in place for recording safeguarding concerns which the management team had oversight of. However, we were not assured that these had been shared with all staff as some staff we talked to said that they had not known about recent safeguardings.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Staff had received training in the principles of the MCA but were not all clear of their responsibilities in upholding those principles. Mental capacity assessments were decision specific but not always person specific. For example, hotel style doors. Hotel style doors are locked from the outside by a key but can be opened easily from inside. Staff told us everyone was given a key, however 21 people had lost the key. This appeared to be a blanket decision and not reflective of everyone’s capability to use the key. Not all DoLS were up to date and had not been renewed as required. This had been identified by the external consultant, prior to our visit, and was being actioned.

Our observations found that people were comfortable with staff, we saw positive interactions, which assured us they felt safe. People and their relatives told us that the service was safe. One person said, “I feel safe here, staff are very kind.” Relatives' comments included, “I trust the staff, if anything happened, they would tell me.”

There were organisational procedures for safeguarding people. These provided guidance about the action to take if staff had concerns about the welfare of people.

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.

Care plans and related risk assessments were not all person-centred or reflective of people’s individual needs. Some care plans contained little guidance for staff to follow to provide consistent care delivery to ensure peoples’ health and safety.

There were concerns identified regarding the records of peoples’ weights and the lack of oversight from senior staff. There was evidence of weight loss over the past six months, and this had not been followed up or actions taken to prevent further weight loss. This was fully discussed and the provider acknowledged the omissions and assured us that these would all be checked and appropriate action taken if necessary.

Some people’s monthly health checks taken by staff had not been followed up, for example oxygen levels for one person had been recorded as 87 % which was very different to their normal level, and no further checks undertaken or discussed with a health professional. Levels below 90% are considered low (hypoxemia) and may indicate a need for medical attention.

Where people lived with additional mental health diagnosis there was a lack of direction for staff of how to manage mental health changes and no monitoring of what worked or didn’t work. For example, staff told us that there was a lack of consistency in how they approached people when they didn’t want personal care. We saw that the care plan did not have specific detail to manage this consistently.

Whilst staff we spoke with had an understanding of people’s care and support needs , care plans that were in place for people who lived with specific care and support needs were not all accurate. This had the potential to impact on safe care delivery. For example, changes to a person’s nutritional guidance, a person’s safe moving and handling had not been made to reflect their most recent risk assessments. The management team acknowledged that there was work to do and were taking action to address the issues.

The provider had not detected and controlled potential risks in the care environment. They had not made sure equipment, facilities and technology supported the delivery of safe care.

The fire grab bag to aid in the event of an emergency event was not easily accessible being locked in an unused treatment room. The grab bag held personal emergency evacuation plans (PEEP) but were not all accurate and in place. This meant that in an emergency, important information was not available. Not all staff had had fire evacuation drills and training. This was brought to the providers attention and the provider arranged immediate training. Fire drills have now been undertaken. We were assured that people are now safe. There was a de-choker in the dining room, but no staff had received training in the use of this equipment. This was immediately removed. First boxes had not been checked regularly and the kitchen first aid kit was missing essential first aid items such as eye wash, blue plasters and burns relief. These were immediately re-stocked. The environment was specifically designed with bespoke features to mitigate risk and reduce stress and anxiety. The provider had considered the specific needs of people living with dementia when designing the environment and there were large spaces and wide corridors.

The environment was safe and well cared for. Care equipment we saw was in good working order and documentation to support regular servicing was seen. There was no clutter, and the home was accessible for people with mobility needs and safe for those who walk with purpose.

Processes ensured the environment was safe and well kept. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuation of the property. Premises risk assessments and health and safety assessments were reviewed on an annual basis, which included gas, electrical safety, legionella and fire equipment.

The provider did not always make sure there were enough fully qualified and skilled staff on duty. They did not always make sure staff received effective support, supervision and development.

Staff supervision meetings were inconsistent, and staff training was not up to date. Service policy at the home stipulated that staff should receive regular supervision meetings, one to one time with their line manager. This was not happening with some staff telling us they had not had supervision for over 6 months. This had been identified by an external consultant and recommenced. The staff training matrix identified staff training was out of date and not kept up to date. The provider had sent an email to all staff regarding their training, and this had given the staff incentive to complete their training. An updated training matrix has been received, and it showed that staff had responded by completing necessary training. There was a plan in place going forward regarding training and staff supervision.

Staff numbers overall were maintained and there was enough staff on duty for each shift. Staff had been recruited safely. Staff files contained the required documents and checks for example, references, photographic identification and Disclosure and Barring Service (DBS) records. Disclosure and Barring Service checks support managers to make safe recruitment decisions.

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.

Staff told us they were well resourced for cleaning and infection control. One said, “Personal protective equipment (PPE) is not an issue, we have enough and also cleaning products and equipment.”

The home provided people with a clean, and well-maintained environment. People’s rooms were cleaned regularly by housekeeping staff and visitors commented positively, with no-one reporting any problems with the standard of cleanliness of the environment and equipment. We visited one room with the person, who told us, “I just moved to the best room in the house, I have doors to the outside.” The room was clean, comfortable with the persons personal effects displayed.

We saw housekeeping staff undertaking cleaning in all parts of the home. Our observation of the environment raised no concerns about safety or cleanliness. People’s laundry was managed well, and the laundry room was clean and well organised, and people were well dressed.

The housekeeping staff understood their role and followed appropriate procedures to keep the home clean. All staff understood their responsibility to reduce the risk of infection and followed infection control guidance. There were posters and training to assist staff in keeping up to date with any changes to infection control measures. Audits were completed to ensure compliance with the procedures and policies of the home. Staff were trained in the use of personal protective equipment (PPE) and of the importance of good hygiene practice.

Visitors told us, “The housekeeping here is really good, and make sure it’s clean and smells nice,” and “They (housekeepers) are good, always busy but the home is spotless.”

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.

Improvements had been made to the management of medicines, following the medication audit in March 2026. However, there were still areas to improve going forward. For example, staff were scribbling out signatures and not striking through, the original signature needs to be identifiable, and not all handwritten medicines and directives were double signed to ensure they had been entered correctly into the medicine administration record (MAR). Protocols for as required medicines were in place but were lacking person specific details and were not linked to a care plan or pain chart to manage effectiveness.

There was a dedicated medicines room, and the trolleys were stored safely. All discrepancies and medicine errors were recorded and investigated and action taken as required. Daily and monthly audits were now being carried out, and any shortfalls were addressed.

Staff who gave medicines had been trained and had their knowledge and skills regularly assessed in the form of competency assessments.