Applecroft 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.

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.

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 was working towards establishing a positive culture of safety, based on openness and honesty. They were working towards learning lessons and starting to embed good practice.

Staff told us they were confident to report any accident or incidents to the nurse or senior care staff. The provider carried out a monthly analysis of accidents, incidents, audits and people’s experiences. This was to identify any patterns or trends and actions needed to ensure safe care. However, there had been no analysis for the months of November and December 2025. This had been added to the services improvement plan and completed retrospectively at the time of our assessment. An analysis for January 2026 had been completed, but there had not been sufficient time to ensure this practice had been embedded at the service.

When events had been analysed, actions had been taken to make improvements to the service. An analysis of incidents between residents had resulted in additional staff training on supporting people living with dementia who had developed sexualised behaviour to express their need for closeness and affection. When investigating the root cause of people at high risk of falling it had been found that one person was stepping over their sensor mat and therefore not alerting staff when they had got out of bed. People living with dementia can experience significant changes in visual perception and staff identified the dark colour of the sensor mat appeared to the person like a big hole. The sensor mat was changed to a similar colour to their flooring and as a result they stepped on the sensor mat and staff knew they were up and about.

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.

People’s needs were assessed before they moved to the service. The service had established relationships with a range of health care professionals including speech and language therapists, occupational therapists and dieticians. Referrals had been made to health professionals in a timely manner and professional guidance was followed. Health care professionals told us that staff provided them with the necessary information about people when it was requested.

Relatives said the staff assisted their family members with organising and accompanying people to medical or hospital appointments. The service had systems to ensure all essential information was available quickly about a person, when they were admitted to hospital.

The provider worked with people and partners to understand what being safe meant to them and the best way to achieve that. Staff understood how to ensure people lived in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff had received training in how to recognise and report abuse and knew how to raise safeguarding concerns both internally and externally. Staff had access to the provider’s safeguarding and whistle blowing policies. The provider had reported safeguarding concerns such as incidents between residents and unexplained bruising to the local authority who is the lead agency for safeguarding. The interim manager and new manager, who came into post on the second day of our assessment, were knowledgeable about the types of safeguarding that had been raised by the service.

People said they felt safe living at Applecroft Care Home. One person told us, “Yes, I feel safe. I’m not scared.” Relatives also told us their family members were safe living at the service. However, there were some concerns that their loved one could be involved in an incident with another service as people were living with dementia. One person said, “I wish I could be better confident he won’t get hurt”. Staff described how they used tactics to distract and calm people who were anxious and took steps to separate people who agitated one another. However, staff also described people from whom there were no obvious signs they were getting anxious. Staff had been reminded to use behavioural charts to help identify any triggers or patterns for people.

There were some inconsistencies in how the provider worked with people to understand and manage risks. Staff were not always guided, nor did staff did always provide care to meet people’s needs that was safe and supportive.

Some moving and handling risk assessments lacked guidance or were not followed by staff. We observed a staff member pulling a person by their shoulders to assist them to sit up in their chair. We spoke to the nurse on duty who confirmed this was neither a safe nor correct way to support them. The provider informed us this staff member received refresher training in moving and handling and had their competency assessed, after it was brought to their attention.

Guidance for staff was incomplete on how to safely hoist a person. Although staff explained which hoist sling loops they used in different situations, there was no detail in people’s moving and handling plans about which sling loops to use to aid safe transfers. Proper loop selection prevents a person from feeling uncomfortable, slipping, or being in an incorrect, potentially dangerous, posture. During the assessment this essential information was added to people’s care documentation. For one person their assessment stated they should be repositioned in bed using a padded slide sheet due to them finding the hoist uncomfortable. However, staff told us they moved the person using the hoist, “which could be difficult as they don’t like it”. There was a risk by not following moving and handling guidance the person was not supported in the safest way.

Other risks in people’s daily lives and relating to their health and social care had been assessed and comprehensive plan were in place to guide staff. This included people at risk of choking, of falling, of skin deterioration and specific medical conditions such as diabetes and epilepsy. Nurses took the lead on keeping people’s skin healthy. For people at risk of skin deterioration, plans guided staff when to reposition people, what equipment they needed to move, and about their diet. Wounds and skin tears were assessed and treated by nursing staff and specialist advise sought when required.

Some people expressed their emotions and anxieties in a specific physical or verbal manner. Staff were guided how to distract and calm people and to look for any triggers. Staff described and care notes confirmed that staff used these strategies with people. This included returning to a person later if they were not receptive to receive support when first approached by staff.

Each person had a personalised evacuation plan with clear guidance for staff and emergency services on the support they would need to evacuate the building safely in the event of a fire. This information was easily accessible. There was also a portable kit of essential items for staff to grab by the front door in the event of a fire.

The provider detected and controlled potential risks in the care environment. However, they did not always make sure equipment and facilities met the specific needs of people living with dementia.

There were regular visual checks of the environment to make sure it was safe and free from hazards. Staff said they were confident to raise any safety issues with the management team. The service had a programme of maintenance, some of which was taking place at the time of our assessment.

Essential servicing had taken place such as the maintenance of gas, water and electricity. Regular checks and maintenance were carried out of fire fire-fighting equipment and moving and handling equipment. Staff practiced fire evacuation to ensure they were competent they knew what to do in the event of a fire.

Although the service was a specialist service for people living with dementia, it was not evident from observations that national guidance had been followed in providing a safe environment for this group of people. A dementia-friendly environment is important for people’s safety as it reduces people’s confusion, anxiety, and distress. Consideration had been given to providing signage, sufficient lighting and uncluttered environments so people who liked to walk could do so. A relative told us, “There is a big open space for her to walk about. No clutter or feet for her to trip on. The corridors have rails on the side to hold onto”. However, we found there was a lack of contrasting colours in the environment to help people safely find their way around their home. One relative said, “The front door of his bedroom could be more personalised. Sometimes, I almost walked into the wrong room as they are all the same colour and just have a number”. There was also a lack of sensory items for people to access and enjoy which helps to give people a sense of purpose and to prevent boredom and anxiety.

The interim manager acknowledged the environment was not fully adapted to meet the specific needs of the people for whom it was intended. They shared plans to redecorate each unit with a theme. During the assessment they shared photographs of boxes which had been placed on bedrooms doors. These had personal items to help people recognise their bedroom. The also provided pictures of sensory boxes they had ordered to go on each unit.

The provider was reviewing staffing levels to ensure there were enough qualified, skilled and experienced staff. They made sure staff received effective support, supervision and development.

The provider used a dependency tool to assess people’s care needs with the number of staff required during the day and night to meet them. The staff rota clearly indicated those people who received one to one support. Staff and relatives told us there were usually enough staff available to support people when they needed it. A relative said, “I’ve never struggled to find staff. Always somebody about. I stayed overnight and staffing was fine at different times.” However, feedback was not so positive about people living in the 2 units on the top floor of the service. Comments included, “Staff and kind and caring but there are not enough staff on the top floor”; and “It can be difficult when there are a lot of people who not independent such as mealtimes.” We observed that staff were especially busy on these two units. A relative told us they had fed this back to the interim manager. “I was told they would take it on board but have not seen any real change.” The interim manager told there were enough staff as staffing levels were regularly reviewed and had been explained to staff and relatives. However, they said a discussion would be held about splitting these 2 units which may allow for additional staffing.

Staff training was comprehensive and included mandatory subjects as well as those specific to the needs of the people living at the service. This included people’s medical conditions such as diabetes, epilepsy and Parkinson’s. Staff took part in face to face practical training to help them understand how a person living with dementia experienced their environment and daily life. New staff completed an induction when they started working at the service and were supported to continue to develop in their roles to ensure they could meet people’s individual needs. A staff member told us, “The induction was good and helped me to do the job well.” Nurses undertook regular training to ensure they had had the specific skills to provide nursing care. Relatives told us that staff had the right skills for their role. A relative said, “The home will send staff for training for syringe drivers. It’ll be useful in the future for end of life care, if he can’t swallow.” A syringe driver is used to administer medicines to people who cannot take their medicines orally.

Staff were safely recruited by undertaking necessary checks on their previous employment and conduct and satisfactory explanations given or any gaps in their employment history. Disclosure and Barring checks (DBS) were completed before staff could work alone. DBS checks provide information including details about convictions and cautions held on the Police National Computer. All these checks help employers make safer recruitment decisions.

Staff said they received the support they needed from colleagues and managers. Staff attended individual or group supervisions and team meetings. These included discussions on specific topic area such as fluid and hydration and staff development.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Staff had received infection prevention and control training and understood what to do to mitigate infection risks. Staff told us how they used protective equipment (PPE) such as gloves and aprons situated around the service. One staff member told us, “We use PPE for each individual resident. If there is an infection, we create a barrier so that infected residents are kept away from the uninfected.” A relative said, “Staff do wear gloves and aprons for hygiene. They had a flu outbreak a few weeks ago and the staff wore masks.”

Housekeeping staff were clear about their roles. They were assigned to a specific floor and staff directed them to any specific areas that required immediate attention. Staff explained there was a daily cleaning schedule including deep cleaning of people’s bedrooms. There were regular walk arounds to check cleanliness and infection control practices. The home was clean on the 2 days of our assessment visit and this was confirmed by relatives. One relative told us, “There are no bad smells in the place. His room is cleaned every day.”

Relatives told us the service was always clean and smelled fresh when they visited. A relative told us when staff dropped their family member’s medicines on the floor by accident, they disposed of them and gave them new medicines. They told us this was good infection control practice.

The service had a 5-star food and hygiene rating, indicating that hygiene standards were ‘very good’.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There were inconsistencies between different parts of the service in how medicines were managed. The service undertook regular internal audits and in addition an external medicines audit had been completed in January 2026. This external audit had made several recommendations and as a result the service had developed an action plan which it was working towards. However, we found some actions had not been consistently implemented across the service and additional areas where improvements were needed. The interim manager ensured all shortfalls we identified in medicines management were investigated, addressed and actions put in place to reduce the risk of their reoccurrence.

Best interest decisions had been held with health care professionals when people lacked the capacity to refuse their medicines and were at risk of harm to their health. Two people’s covert medicines administration did not follow best practice guidelines. For one person, the pharmacist had advised not to crush one of their medicines as it reduced its effectiveness and to obtain it in liquid form. Although staff reported they were not crushing this medicine, they did not follow the pharmacists advise and obtain the medicine in liquid form, until it was brought to their attention. For another person, staff had been advised to crush all their medicines, despite 1 of their medicine being potentially hazardous to staff in the crushing process. Although staff reported they were not crushing this medicine, they were not aware of the potential hazards. A risk assessment was put in place during the assessment to ensure staff’s safety.

Some medicines remain effective for a specific period and staff checked medicines administered had not expired. There was 1 exception to this best practice where staff had given a person paracetamol in December 2025 that had expired 6 months previously. The nurse completed a self reflection and checked with a health professional who confirmed no harm had been caused to the person. Two of the units were not storing waste medicines, which were at higher risk of misuse, securely in a locked cabinet. The interim manager sent evidence during the assessment that smaller containers had been purchased which fitted in the existing secure medicines cabinet. We found records for 1 person’s pain patch did not evidence it had been rotated on their skin as required on some days to ensure healthy skin. The provider investigated and found this inconsistency was not systemic throughout the service. A message was sent to staff to remind them that some pain patches require rotation and others need to remain on the same site for 4 weeks. The interim manager told us during the assessment that patch paperwork was being brought to daily meetings to check for accuracy.

Nurses and care home assistant practitioners who supported people during the day and night had been medicines trained to ensure people could receive their medicines as prescribed by their doctor. A person told us, “My pain relief is always on time.” Clear records were kept of when people needed their medicines and when they were given. Staff were aware that some medicines needed to be given at specific times to ensure their health. There were protocols in place for people who had been prescribed medicines to be taken when needed. This included medicines to reduce people’s anxiety and if a person had an epileptic seizure. Staff were given guidance about which part of a person’s body topical creams should be applied.

People had their medicines reviewed regularly and appropriate risk assessments had been undertaken for people prescribed anti-psychotic medicines for their mental health. The service understood the important of working closely with a healthcare professional to find the right medication and dosage whilst managing any side effects.A relative told us, “There is always a nurse on duty and they’re excellent. I’ve discussed medicines a lot with them and they’ve been significantly reduced. She’s a lot better, less drowsy and happier with less dosages.”