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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. At our last assessment we rated this key question inadequate. At this assessment the rating has remained 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 ways people’s medicines were managed safely, the safety of the environment and poor infection control practices. The service was also in breach of legal regulation in relation to people not being protected from abuse, safe staff levels and staff not receiving appropriate training and supervision.

This service scored 25 (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. At the previous inspection we found incidents and behaviour records were not completed in detail. There was a lack of information on what actions had been taken to mitigate further incidents occurring. We found this concern still remained. One relative told us they were not always given information on how their loved one sustained an injury. They told us, “A couple of weeks ago (person) had a big bruise on their shoulder, I asked (a senior member of staff), and they said they didn’t know how that happened.”

Staff were not always recording on incident forms or behaviour records when people had distressed behaviours. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. There was also no evidence that debriefs were taking place to understand and learn from incidents.

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. Whilst there had been no new people admitted to the service since the last inspection, there were concerns around people being admitted back to the service after a stay in hospital. We found where people had been discharged from hospital, and their needs had changed, there was no updated information in their care plans relating to the management of risks. Leaders told us there were people in the service whose needs they believed they could not meet in a safe way due to their distressed behaviours. Sufficient action had not been taken to address this.

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 abuse, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. At the previous inspection we found safeguarding incidents were not investigated appropriately or reported to the local authority. We found on this inspection this had not improved. People told us they did not always feel safe. One told us other people would frequently go into their room. They said, “The worst thing in here, people think they can come in my door and help themselves to what’s in there [their room].” There was a mixed response from relatives around whether they felt their loved ones were safe. Comments included, “(Person) feels safe, no concerns” and “I don’t feel (person) is safe, I check (person’s) arms for bruising.”

We observed a member of staff kiss a person on the lips which was initiated by the member of staff in a communal lounge. We saw from their plan that the person lacked capacity and would not have been able to consent to this intimate act taking place. The member of staff and other staff that were present in the lounge had not recognised that this act was inappropriate and a potential act of abuse.

There were multiple incidents where people sustained injuries from other people living at the service. Leaders had not taken sufficient action to investigate this and report to the local authority safeguarding team. There were also instances of alleged safeguarding concerns made about staff working at the service, yet robust action had not been taken to address this. Staff told us they would report any safeguarding concerns to their line manager however we found they were not doing this. Staff also did not know how to escalate safeguarding concerns to the local authority. We were present when a person advised a member of staff about another member of staff being verbally abusive. The person told the member of staff, “(Staff member) was nasty.” The member of staff took no action in relation to this and did not report this to any leaders at the service. We reported this to the provider and manager. This placed people at further risk of abuse and neglect.

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. Since the previous inspection there has not been sufficient improvement around the management of risks. This included, but was not limited to, the risk of pressure ulcers, moving and handling, dehydration, and falls.

There were people that were at high risk of malnutrition and were required to be weighed weekly. Records showed these people had not been weighed since March 2025. Relatives fed back they did not feel their loved ones were supported with meals appropriately. One told us, “They don’t encourage people to eat their meals, they just take the plate and say, ‘you finished?’” We observed an example of this during lunch when a person had not eaten a lot of their meal. The member of staff asked the person, ‘Are you done?’. The person told the member of staff they did not enjoy the meal however an alternative was not offered, and the plate was taken away. A person told us, “The food is not too bad, you just don’t get enough.” This placed people at further risk of malnutrition.

One person had a pressure ulcer and slept on a pressure mattress. However, the mattress was not set at the correct weight meaning the effectiveness of the mattress would be decreased. Health care professionals fed back that people were not supported appropriately with the management of pressure sores and skin integrity. One health care professional told us, “Some staff are laid back and not proactive.”

Where people’s health concerns had changed, their risk assessments had not been reviewed to reflect this. Staff we spoke with told us they did not read people’s risk assessments and solely relied upon other staff to advise them. When asked about how they knew about people needs, a senior member of staff told us, “I am given my allocation and I just need to make sure they are watered, fed and toileted.”

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. This had not improved sufficiently since the last inspection. We found furniture in people’s rooms was either degraded or broken including drawers on cabinets that were hanging off. In one room that was accessible to people, there was a large television balancing on a cabinet. This posed a risk of falling on a person. Cupboards with electrical wires and hot pipes had been left unlocked and accessible by people that wandered with purpose. There were radiator covers that were not fixed to the wall which posed a risk to people if they leaned on them. Staff were still relying upon only 1 electronic tablet for all staff to review people’s care needs.

People were not protected from the risk of an emergency occurring in the service such as a fire. Staff struggled to unlock the front door on the day of our visit. Staff told us this was one of the emergency fire exits. People’s ‘Personal Emergency Evacuation Plans’ (PEEPS) had incorrect information on where people’s rooms were, and the photos of people did not reflect how the person now looked. Some PEEPs contained information for people that no longer lived at the service. Not all staff we spoke with were familiar with the fire safety and had not been given any training. This meant that people may not be supported appropriately and safely in an emergency.

At the previous inspection, the provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs. We found on this inspection this had not improved. We were told by leaders there needed to be 5 carers on duty during the day (including a senior carer). We saw from the rotas from the 14 April 2025 and 25 May 2025, there were 9 days where there were only 4 staff on duty. In addition, staff were only completing 1 shadow shift before they were rostered to work on shift. This would not be sufficient time to ensure they knew and understood people’s care needs.

We found that agency staff that were new to the service were not provided with a sufficient induction around how to provide safe care to people. Staff confirmed to us that agency staff were not provided with a summary sheet of people’s needs. One senior member of staff told us of an agency staff who was working at the service for the first time on the day of our visit, “I gave (member of staff) a list of allocations [a list of who they would be supporting]. (Member of staff) has had no chance to read them (care plans).” On observation we found this member of agency staff lacked knowledge of people’s risks and needs. They frequently just walked around the lounge areas unsure of what they needed to do. Another regular member of agency staff told us they did not fully understand people’s needs and said they would be led by senior carers on how the support people received should be given, “As they know them better.” This placed people at risk of receiving unsafe care.

We found staff were not deployed effectively to ensure safe care at night. We saw from reports there were 15 incidents at night where people had unwitnessed falls or people were found by staff during early morning personal care with skin tears or bruising on people of an unknown origin. There was no system in place to ensure staff were recording regular checks of people when they were in their rooms.

Whilst there were staff who received training, this was not effective to ensure they were competent to deliver care. For example, we observed staff not using moving and handling equipment for people in a safe way. We saw 1 person being hoisted and the sling had not been properly positioned around them, and this risked them falling from the sling. Relatives fed back that their loved ones were not supported safely when they were being assisted to stand. One relative said, “[Staff] picked (person) up under their arms and (person) cried out, ‘You’re hurting me’.” A health care professional told us staff were not elevating people’s legs in a safe way, and we saw evidence of this. One person legs were placed on a small stool and there was not enough space for both heels to sit comfortably on there. As a result, 1 foot kept slipping off. This placed the person at risk of harm.

Leaders 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. We found there had been improvements with the strong smell of urine we identified at the previous inspection. However, this was not consistent and there were still areas in the service that still had a strong smell of urine including the reception area and 2 people’s bedrooms.

Staff were not always following good infection control practices. Staff were not separating out people’s soiled and non-soiled clothing. The laundry room was not set up to ensure good infection control, there was little space for staff to place washed clothing. Other areas around the service were not clean and posed a possible infection control risk. This included degraded moving and handling equipment and sinks. The sluice room where staff needed to sterilise people’s continence aids was out of order, so staff had no dedicated place to do this. This was also a concern raised by visiting health care professionals.

There were some aspects to infection control that had improved since the last inspection. Aside from 2 people’s bedrooms, other people’s mattresses and bedding no longer smelled of urine. We observed staff responded quickly to people who had been incontinent. They cleaned people’s cushions where they had been sitting.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We identified on the previous inspection that there were multiple gaps in people’s medicine administration records (MAR) and there was a lack of ‘as and when’ guidance for staff on when to administer pain relief. This is particularly important given most people had advanced dementia and may not be able to articulate when they were in pain. These concerns still remained as there were still a lack of guidance in place. This meant there was a risk people were not always receiving their medicines when needed.

As before, there were photographs missing on some people’s MARs. This meant for any staff not knowing people well, there was a risk they would give the medicine to the wrong person. On the day of the visit, we observed a member of staff signing to say a person had their medicine before it was administered. Staff were also not always recording the temperature of the medicines room. Recording the temperature of a medicine room is crucial to ensure medicines are stored within the correct temperature range, maintaining their efficacy and safety.