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• 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 and there was limited assurance about safety. There was an increased risk that people could be harmed.

During this inspection we identified a breach in regulation in relation to staffing.

This service scored 53 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. However, learning culture was an area that required further development. Lessons learnt were not consistently recorded to show how they had been identified to embed good practice.

Before the inspection, the provider had kept us informed of difficulties they were experiencing in relation to staff culture and management of the service. They told us this had a negative impact on people’s experiences and outcomes. They advised us of the actions they were taking to address these. This demonstrated the provider’s openness and honesty and commitment to make improvements.

The provider had policies and procedures for managing safety events such as falls, accidents and incidents. However, improvements were required to ensure these were consistently followed.

At this inspection, we reviewed incident data for the last 3 months. Whilst overall incidents were low level, records showed staff were recording limited information and this impacted any meaningful assessment and analysis to support any learning to reduce further recurrence. Whilst the manager told us they held meetings with staff to discuss lessons learnt and actions, this was informal and not recorded. Without written records there was a risk of staff providing inconsistent care.

The manager identified staff required additional support and upskilling in record keeping and gave examples of how this was being addressed.

The monthly analysis of falls showed a decline in the number of falls since March 2025. This was a result of upskilling the staff in understanding their role, responsibilities and accountability, including reviewing staff deployment.

Relatives confirmed they were notified of any incident their family member had experienced.

The provider’s complaint policy and procedure had not been fully adhered to. From the 2 complaint examples reviewed, these showed duty of candour had been met and investigations, actions and outcomes completed. However, not all complaints and concerns the provider had received were shared with us. The manager advised when they commenced, the amount of complaints and concerns were overwhelming and whilst they assured us they were all responded to, they were unable to provide evidence to confirm this. During the inspection, the manager showed is a new monthly complaints summary document that had recently been implemented to capture this information. This is important information to enable the provider to review any reoccurring themes and patterns and actions required to embed good practice.

The provider had a service improvement plan they had developed with the support from the local authority that was driving improvements.

The provider was making improvements in how they worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. This included improving continuity of care, including when people moved between different services.

At the time of the inspection, the provider had put a voluntary suspension on new placements. They had recognised they needed to make improvements across the service and to allow time for new and improved systems and process to embed and be sustained and to stabilise the staff team. This showed the provider’s commitment in further developing the service to enable people to experience positive outcomes.

The manager told us of the provider’s referral process and how they took responsibility for completing the pre-assessment and transition procedure. This confirmed people’s individual needs were assessed, including any resource requirements to enable people’s needs to be safely met.

At the time of the inspection, the management team were reviewing and redeveloping people’s care plans and risk assessments, to ensure they were fully reflective of people’s current care needs enabling staff to provide safe and consistent care. From the sample of newly written care records, we found overall they reflected people’s current care needs. However, further actions were required to ensure all information was consistently accurate. At the time of the inspection, people and relatives had not been involved in the development and review of care plans, the manager recognised this and had plans to introduce a formal review process to include them.

People had ‘grab sheets’ that provided others such as ambulance and hospital staff of important information about people’s individual care needs, preferences, including advanced decisions to enable consistency in care delivery as people moved between services. We confirmed this information was accessible to staff at all times.

Feedback from external healthcare professionals told us communication and ways of working with the service, had been difficult at times, however some improvements had been made recently and were ongoing.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider had not consistently shared concerns quickly and appropriately.

The multi-agency safeguarding policy and procedure had not been fully adhered to. The policy refers to any safeguarding incident, allegation and or suspicion of abuse must be reported to external agencies as soon as possible, without delay. At the time of the inspection, there were a high number of local authority ongoing safeguarding investigations. Some of these safeguarding incidents were historic, for example occurring in 2024 or early 2025 and were identified and reported to the local authority and us, by the current manager. This showed a lack of management actions and senior leadership oversight at the time of these safeguarding incidents and concerns.

The provider had safeguarding and whistle blowing procedures and staff confirmed they were aware of them. Staff received refresher safeguarding training and demonstrated an understanding of their role and responsibilities in protecting people from abuse and avoidable harm. A staff member told us they received annual safeguarding training and this was confirmed by the staff training matrix. They said, “I feel confident raising abuse concerns, including issues such as staff shortages. When concerns are raised, the deputy manager comes to assist.”

Safeguarding information had been made available to people and visitors. Resident meeting records confirmed safeguarding was discussed, people were supported to understand what safeguarding means and how to report any concerns.

People and relatives raised no concerns about risks relating to abuse but consistently raised concerns about staffing levels, that they felt put people at potential risk of avoidable harm.

People were protected lawfully in line with the Deprivation of Liberty Safeguards (DoLS). The provider had a DoLS policy and procedure, and staff had received required training. Where people had a DoLS authorisation a tracker and care plan were in place. These informed staff of the authorisation and expiry date and details of any conditions. Where conditions had been made we confirmed these were being met.

Our observations confirmed staff supported people safely with moving and handling, using best practice guidance. This included good responses from staff in meeting people’s emotional needs such as periods of heightened distress and anxiety.

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.

People and relatives told us and records confirmed, they were not consistently involved in discussions and decisions about how risks were managed. The manager told us they were aware of this and going forward, they had plans to implement 6 monthly review that would involve the person and or their relative and representative.

Risks associated with people’s known clinical risks, had not been reviewed and updated in a timely manner and without using a risk based approach. At the time of the inspection, the management team were reassessing people’s care needs and rewriting care plans and risk assessments. This was to ensure staff had up to date guidance that reflected people’s current needs. We reviewed a sample of care plans and risk assessment; this included a sample of historic care records and updated ones. Some concerns were identified in how known risks were managed. For example, a person had a catheter but had no current care plan or risk assessment. The person's medical care plan referred to them having a catheter but provided no guidance to staff of care required or signs and symptoms of an infection and actions required. This person’s care records were reviewed in April 2025. However, the review had failed to identify this missing information. When this was discussed with 1 of the deputies, we were told it would be picked up in the current care plan review. This demonstrated a lack of concern or urgency to get this completed as a priority.

A recently updated care plan and risk assessment had contradictory information about a person’s known choking risk. For example, information stored in the kitchen for catering staff and in the care plan summary for care staff, stated the person required a level 5 mince and moist diet as recommended by the speech and language team. However, their nutrition care plan described them having a level 7 normal diet.

These risks were mitigated because staff were knowledgeable about people’s care needs and the manager took some immediate action to address these shortfalls. However, a lack of consistent, detailed and up to date information put people at increased risk of harm.

The provider had a positive approach to risk taking. For example, people received opportunities to access regular community activities of their choice, this included visits to the local leisure centre swimming pool, attending the local temple and church. The activity coordinator told us how a risk assessment for each person was completed for every community activity.

We also observed how people were supported with lifestyle choices. For example, when people chose to smoke this was risk assessed, and support was provided to manage this safely for the person and others.

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

The provider’s service improvement plan included improvements to the environment. The provider had invested in the service and had made improvements to the safety of the environment, such as replacing fire doors, and had further improvements planned. Ongoing refurbishment plans were also in place. Assistive technology was used to support safe delivery of care.

The local authority completed a health and safety audit in June 2025. This was broadly compliant and where a partial compliance and a noncompliance action was identified, and some minor recommendations made, these were either completed or in the process of being addressed by the provider.

The provider had relevant health and safety policies and procedures to ensure the service, premises and equipment were serviced, maintained and monitored.

Risks in relation to fire safety and legionella; a water based bacteria that can cause serious illness, were assessed, mitigated and monitored. Staff had received fire safety related training. Personal emergency evacuation plans were in place and fire checks and drills were completed to ensure people would be supported safely in the event of an emergency evacuation.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Improvements had been made and were ongoing, in relation staff receiving effective support, supervision and development. Ongoing improvements were being made to how staff worked together to provide safe care that met people’s individual needs.

Staffing levels were not sufficient in meetings people’s individual care needs and safety. Before the inspection we had received high levels of concerns from a variety of sources about unsafe staffing levels at the service. This theme continued on inspection and post inspection.

The provider had a dependency tool to support them to identify staffing level requirements. However, we found no evidence that the dependency tool had been used. The manager told us the provider informed them of the staffing levels. The manager confirmed they had not yet completed the dependency tool, as they needed to reassess people’s care needs to accurately assess what people’s dependency needs were. Following the inspection, the senior leadership team told us they had completed a monthly dependency tool for the last 12 months and provided an example of this.

We reviewed the staff rota, discussed staffing levels and deployment of staff, and people’s dependency needs with the manager and reviewed a sample of care records. We also completed observations of staff engagement with people, including people’s mealtime experience. We were aware care staff numbers were reduced in an afternoon and that catering staff finished at 3pm, meaning care staff had to serve tea from the kitchen, reducing further people’s access to care staff. We concluded staffing levels were not sufficient, and people’s dependency needs had not been assessed in a timely manner, this put people at greater risk of harm.

Staff had not received sufficient training to meet people’s individual care needs and clinical risks. For example, catheter care is a delegated heath care task that requires staff to receive training from a healthcare professional and their competency assessed. This had not been completed. People had clinical care needs in relation to diabetes, epilepsy, skin integrity, dysphagia (swallowing difficulties) and sensory loss. However, the training matrix did not include these specific training areas. We asked a member of the provider’s quality team who confirmed this was correct and that in response to our query, had raised it with the training and development team to follow up. Whilst staff demonstrated an awareness of these care needs, we were not sufficiently assured staff had received training required to safely and effectively meet people’s care needs. This put people at risk of harm.

Staff competencies in the delivery of some care tasks including medicines administration were completed. The manager shared a manager’s competency assessment toolkit that was in the process of being implemented. This showed staff competencies were due to be enhanced.

Recent improvements had been made and were ongoing, in relation to staff supervision and appraisal support. Staff confirmed these improvements were recent, and they spoke positively about the current manager’s support. Whilst they told us further improvements were required, they had begun to feel better supported.

Staff were recruited in a safe way. Appropriate checks were carried out before employment was offered so that as far as possible, only suitable staff with the right skills and experience were employed. Induction training was provided to new staff and this included ‘shadowing’ experienced staff.

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.

The provider had an up to date infection prevention and control policy and staff had received relevant training.

All areas of the service were visibly clean. Staff had access to personal protective equipment and knew how to safely manage waste. There were enough domestic staff on duty who followed cleaning schedules in line with best practice guidance. The manager showed us new and improved cleaning schedules that were in the process of being implemented.

Overall, people and relatives were positive about the cleanliness and hygiene of the service. A relative said, “It's [environment] clean and smells lovely.”

Staff knew how to manage any infectious outbreaks, when to use personal protective equipment (PPE) including before and after personal care and at mealtimes. Staff confirmed there were good supplies of PPE and described how clinical waste was disposed of safely.

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. The following medicine shortfalls were identified and had not been identified through the provider’s internal medicine audits and check.

There was a lack of oversight in ensuring medicines were being stored safely. Room temperature where medicines were stored was recorded daily. However, from records available, temperatures above 25 degrees had been recorded for the last 3 months. This is above safe storage guidance. We were told an air conditioning unit had been ordered, however there were no mitigation plans despite the high temperatures being recorded. Whilst we were assured there had been no impact on medicines this was a potential risk.

Fridge temperatures were recorded daily. However, we saw examples where the maximum temperature went over 8 degrees and the minimum below 2 degrees for over a month. This exceeded safe storage guidance. Again, no action had been taken to address this issue. When asked, staff did not know how to reset the fridge thermometer and confirmed this was not done.

We raised the concerns about medicines storage and monitoring arrangements with the manager, and they took immediate actions to address these risks.

We also identified medicines were not consistently dated when opened. Prescribed medicines to be administered when required, did not always have a protocol to instruct staff of when and how to administer. However, some instructions were recorded in medicines care plans. We also noted the controlled drugs register had not been completed correctly. Whilst this had not impacted people’s safety, it showed a lack of understanding of the legal requirements and best practice when managing controlled drug records.

We observed staff administer people’s prescribed medicines safely, following best practice guidance. Staff responsible for administering and managing medicines, had received required training and had their competency assessed.

People were supported to have their medicines reviewed by the GP. People and relatives raised no concerns about the management and administration of medicines