The Flowers Care Home Limited

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, the way people’s medicines were managed safely, safeguarding people from potential abuse or harm, the safe management of the environment, staffing and fit and proper persons employed.
 

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 effective systems to ensure that lessons were learned from incidents or near misses.

Staff were not consistently monitoring people, which meant potential incidents may not have been noticed, recorded, or used to improve practice. For example, 1 person was observed in another person’s bedroom wearing their belongings. Staff were unaware this had occurred and did not report the incident to the staff on the next shift during handover. This failure to record and communicate incidents meant risks were not addressed, and unsafe practices could be repeated.

Where accident and incident forms had been completed, we found no evidence follow-up checks were undertaken to ensure the measures identified as required were implemented consistently, or that they were effective.

These failures had a significant impact on people using the service. People were placed at ongoing risk of harm because incidents were not consistently identified, analysed, or used to improve care. Staff were unable to learn from previous events, and unsafe practices, such as unsupervised access to bedrooms, remained unaddressed.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They 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.
People with identified mental health needs had been admitted to the service. Professionals confirmed some people’s mental health was their primary care need. The provider did not hold the mental health service user band. This is formal approval that confirms a service has been assessed as suitable to care for people with mental health needs. A s a result, there was no assurance that staff had the appropriate skills, training, or competence to meet people’s mental health needs, or that the service was suitable to safely accommodate them.
Although pre-admission assessments had been completed, these were not consistently accurate or reliable. For example, 1 person’s pre-assessment, completed by a member of the management team, stated they had ‘no communication needs’, despite a nursing assessment identifying the person required an interpreter due to an inability to speak English. In another case, a care plan referred to a person as having a learning disability; however, this was not identified in the pre-assessment and was not supported by a confirmed diagnosis. These inconsistencies demonstrated ineffective assessment processes and poor information-gathering, which increased the risk of people receiving inappropriate or unsafe care.
 

We found significant failures in the provider’s safeguarding systems. 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.
Observations across the 3 days of onsite assessment highlighted continuous failures to maintain people’s safety. A safeguarding file was in place; however, it did not contain an overarching index, which made the file difficult to navigate and limited effective oversight. In addition, the most recent analysis and monthly review of safeguarding incidents had been completed in May 2024, with no evidence of any further analysis or review. This meant the provider could not demonstrate effective monitoring, learning, or improvement in safeguarding practice.
We were not assured the provider was taking all necessary and appropriate steps to safeguard people where risks were known. For example, 1 person was able to turn off their sensor beam and leave their bedroom without staff knowledge, despite a risk assessment being in place and staff being aware of the risk. Sufficient actions were not taken to mitigate this risk.
Furthermore, this person and 1 other person using the service were known to enter other people’s bedrooms and had been named in a serious safeguarding incident in November 2025. The provider had failed to take effective action to address these known risks, which placed people using the service at increased risk of harm.

We found significant failures in the provider’s safeguarding systems. 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.
Observations across the 3 days of onsite assessment highlighted continuous failures to maintain people’s safety. A safeguarding file was in place; however, it did not contain an overarching index, which made the file difficult to navigate and limited effective oversight. In addition, the most recent analysis and monthly review of safeguarding incidents had been completed in May 2024, with no evidence of any further analysis or review. This meant the provider could not demonstrate effective monitoring, learning, or improvement in safeguarding practice.
We were not assured the provider was taking all necessary and appropriate steps to safeguard people where risks were known. For example, 1 person was able to turn off their sensor beam and leave their bedroom without staff knowledge, despite a risk assessment being in place and staff being aware of the risk. Sufficient actions were not taken to mitigate this risk.
Furthermore, this person and 1 other person using the service were known to enter other people’s bedrooms and had been named in a serious safeguarding incident in November 2025. The provider had failed to take effective action to address these known risks, which placed people using the service at increased risk of harm.
 

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, supportive and enabled people to do the things that mattered to them.
Despite most care plans and risk assessments being reviewed monthly, risks to people’s safety were not effectively managed. Known risks were not acted upon, and mitigation measures were either insufficient or not implemented.
One person was able to bypass the sensor mat in their bedroom. Despite staff being aware of these risks, no effective action was taken to prevent this. This person was known to be at risk of falls and assessed as unsafe when using the stairs unsupervised and subsequently sustained a fall at the top of the stairs. This demonstrated a failure to manage known risks and take timely action to reduce harm.
Some people were known to enter other people’s bedrooms. Staff were informed that this was actively occurring on day 2 of the onsite assessment; however, no action was taken to mitigate the risk. One person was later found in an unoccupied bedroom assigned to a female, wearing personal items belonging to her and had caused damage to her bed. One staff member told us, “We do not have time to complete all of the safety checks we are just too busy.”
We also found the provider did not have safe systems or processes in place to monitor people’s needs when they were cared for in bed. One person was placed on permanent bed care in December 2025. Although care plans and waterlow risk assessments identified the person as being at high risk of pressure damage, no repositioning records were implemented until 9 January 2026.
In addition, 1 other person was cared for in bed and had a waterlow risk assessment that identified them as being at very high risk of pressure damage. A review of repositioning records identified multiple gaps of between 5 and 10 hours where no repositioning had been recorded. This person had a known history of pressure damage. These failures placed people at increased risk of avoidable harm.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.
The environment was not safe or well maintained and did not adequately protect people from avoidable harm. There were significant concerns about the safety of people who were able to access the stairs without staff supervision. Staircases were steep and narrow, and there was no alert or monitoring system in place to notify staff when people used them. Several people using the service had been assessed as being at risk of falls, and their risk assessments stated staff should discourage them from using the stairs unsupervised. Despite this, we observed multiple occasions where staff did not intervene or were not present when people were using the stairs. This placed people at risk of serious injury or death from a potential fall.
We were not assured the premises and equipment were safe, as the provider was unable to provide required certification during or following the assessment. This included evidence of Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) servicing records for hoists and slings, a valid gas safety certificate, and records of temperature checks for water outlets. As a result, we could not be assured that essential safety checks and servicing had been completed in line with regulatory requirements.
We also identified serious concerns regarding fire safety. West Yorkshire Fire and Rescue Service had completed a fire risk assessment in June 2025 and taken enforcement action against the provider due to multiple serious failings. The provider was unable to provide any evidence or assurance that the required actions had been completed to address these failings. In addition, a review of personal emergency evacuation plans (PEEPS) identified that 4 people using the service did not have PEEPs in place.
These environmental and fire safety failures placed people at significant and ongoing risk of avoidable harm, including the risk of serious injury or death in the event of a fall or fire-related emergency.
 

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.
Staffing levels and staff deployment were not safe and did not meet people’s assessed needs. The provider shared their dependency tool, which identified 4 care staff were required on each early shift. However, on the first day of the assessment, there were only 3 care staff on duty, 1 of whom was the senior staff member responsible for administering medicines. We reviewed the rotas and found this was the normal staffing levels scheduled. This meant the provider had not followed their own dependency tool and had failed to deploy sufficient staff to safely meet people’s needs.
We also found the dependency tool did not take account of the layout of the service, known environmental risks, or additional factors such as staff undertaking multiple roles. Even where 4 care staff were deployed, as on day 2 of the assessment, staffing levels remained insufficient to safely complete all required tasks while meeting people’s basic care needs. For example, during each shift staff were expected to cook meals, provide personal care, complete 30-minute safety checks for all people, administer medicines, support activities, and, after 12:00, undertake cleaning and laundry tasks. One staff member told us, “It’s hard to keep an eye on every single resident when you only have a certain amount of time.” This level of workload increased the risk of care being delayed or omitted.
The provider was unable to assure inspectors staff had received appropriate training. The provider did not have access to a training matrix following the departure of the registered manager and therefore could not demonstrate staff were suitably trained or competent to carry out their roles safely.
Recruitment practices were not safe, and the provider had not followed their own recruitment policy. Of the 3 staff files reviewed, 2 did not contain evidence of practical manual handling training completed as part of induction. One staff file contained no record of previous employment history, and 1 staff member had no references obtained from previous employers, with only personal references from friends on file.
Inspectors also found a high reliance on agency staff, particularly on night shifts, where 2 of the 3-night staff were routinely agency workers. Agency staff observed during the assessment did not demonstrate sufficient knowledge of people using the service, indicating they had not received a thorough induction to enable them to safely meet people’s needs.
These staffing failures placed people at increased risk of unsafe care and avoidable harm.
 

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
Despite the provider having infection prevention and control policies and cleaning schedules in place, these were not followed in practice and infection prevention and control (IPC). arrangements were not effective.
Only 1 staff member was employed for 4 hours a day to carry out cleaning and laundry duties (between 08:00 and 12:00), 6 days per week. Outside of these hours, there was no designated staff member responsible for cleaning high-touch areas, communal areas, or people’s bedrooms. As a result, large areas of the service were not kept clean. We observed sticky floors in bathrooms and the clinic room, as well as a strong odour of urine throughout the service. This was particularly evident in 1st floor corridors and bedrooms.
We identified multiple cleanliness concerns in people’s bedrooms. These included stained bedding, mattresses without protective covers, stained mattresses, and bedrooms that were visibly unclean. Laundry practices were not hygienic, and the laundry floor was damaged and flaking. This compromised the integrity of the flooring and created infection prevention and control risks due to the increased potential for cross-contamination.
One staff member told us, “Carers only have time to do a little spot cleaning, not proper cleaning, we just didn’t have time.” A staff member also informed us, “One male walks around and we would sometimes find him urinating near the main door, or outside of the lift. We should have had something in place for this.”
Although staff were observed wearing personal protective equipment, IPC practices were not consistently followed. For example, 1 staff member was observed throughout their shift with their hair worn loose rather than tied back, and not all staff were compliant with the requirement to be bare below the elbow.
These failures demonstrated a lack of effective infection prevention and control systems and placed people at increased risk of infection and avoidable harm.
 

Medicines were not consistently managed safely.
Controlled drugs recorded in the controlled drugs register were not routinely checked to ensure stock levels remained accurate. Some controlled drugs had remained in the service for several months after the person they were prescribed for had left the service. Inspectors also identified entries in the controlled drugs register where the medication was no longer present in the service. As a result, the provider was unable to account for all controlled drugs or provide assurance that stock balances were accurate.
Inspectors found that medicines prescribed to be taken up to 4 times a day on a ‘when required’ basis did not consistently have the timing of administration recorded. This meant inspectors could not be assured that staff were observing the required 4-hour intervals between doses, which increased the risk of people receiving unsafe doses of medicine.
Medicines storage arrangements were not safe or well maintained. Temperature checks for the clinic room where medicines were stored had not been completed between 16 December 2025 and 5 January 2026. Due to gaps in monitoring records, inspectors could not be assured that medicines had been stored within safe temperature ranges. Inspectors also found the medicines cabinet was not clean. Debris and staining were present inside the cabinet, the top of the cabinet was sticky to the touch, and medicine containers were visibly unclean and stained.
However, inspectors observed that the majority of medication administration records had been completed, with minimal gaps, which demonstrated that people generally received their medicines as prescribed.