Pittsmead Grange 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.

This is the first assessment of 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.

The service was in breach of legal regulation in relation to the management of medicines and safe care and treatment.

This service scored 50 (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 and the registered manager 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 or follow process to report safety events.

Policies and procedures were in place for responding to and managing incidents and accidents. However, these were not always effective. While accident and incident forms were completed, required follow‑up actions and recording were not always undertaken consistently. For example, a manager investigation record noted that post‑fall observations were not carried out for 48 hours following an unwitnessed fall.

The registered manager and provider did not always ensure systems for sharing accurate information with people and healthcare partners were robust enough to consistently support safe care. This had the potential to affect continuity of care, particularly where people received support from external healthcare professionals.

Assessments of people’s needs, risks and wishes were completed on admission. However, some assessments and care records were not always sufficiently detailed, consistently reviewed or fully reflective of people’s needs. In some cases, records contained contradictory information about people’s health needs, which could increase the risk that healthcare professionals did not have access to accurate information. One visiting healthcare professional told us they were not confident processes would be followed when attending to administer and manage one person’s medicines. The registered manager addressed this immediately by speaking with the healthcare professional to strengthen communication and working relationships.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that due to an inconsistent approach to ensuring the principles of the MCA were followed.

The provider did not always ensure systems were fully effective in supporting people and staff to apply safe care practices in line with people’s rights and legal protections. This included inconsistencies in the application of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), which had the potential to impact how safety was understood and achieved for some individuals.

Staff promoted people’s rights; however, they did not always work consistently within the principles of the MCA and Code of Practice. Some people had not been appropriately assessed where they lacked capacity to consent to aspects of their care. The provider had identified these shortfalls prior to assessment and had a central action plan in place, which was being progressed at the time of the assessment. The provider maintained a DoLS tracker and had requested legal authorisations where restrictions were in place. We identified that some historic applications and renewals in 2025 had not been submitted in a timely way, creating a risk of unlawful restriction. The provider had taken action to improve oversight, and applications were being submitted more consistently at the time of our assessment.

Despite these concerns, people and their relatives told us they felt safe with the staff that supported them. Comments included, “I do feel safe here with the staff working here”, “I [feel safe] because the carers who I have dealt with here have always been attentive and dealt with the issues I have had”, “Yes, feel safe. When they do arrive, they give their all to help”, and “I feel safe but I don't think there is enough [staff].”

There were safeguarding policies and procedures in place and staff were trained to recognise and respond to concerns, potential abuse and 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.

People told us they were not always involved in planning and managing their needs and risks. Comments included, “I feel that they need more staff. I have not been involved in the planning”, and “Not really no, it is day by day.” A relative told us, “I think initially we sat down with [staff] who did the assessments for [relative] needs and requirements. We have not since then, but if we have concerns for example about medication we will go to reception or to where the senior staff are.”

Risks to people were not always identified, assessed, documented and reviewed within their plan of care. This meant people did not always have detailed reflective care and support plans to guide and support staff to manage risks. For example, a person’s mobility support plan documented the person was at high risk of falls, however, their falls risk assessment failed to provide detailed guidance for staff on risk mitigation and how best to safely support with mobility needs. Their moving and handling assessment documented that there was no history of falls which was contradictory to the person’s mobility support plan. The care plan documented the person had asthma and this was rated as a medium risk. However, there was no detailed risk assessment in place to manage this risk and their condition, and no guidance in place for staff on what actions to take should the person become breathless or suffered an asthma attack.

Another person’s care records documented that they were at risk of choking. Their hydration support plan recorded that they required fluids to be thickened to help prevent the risk of choking. However, there was no choking risk assessment completed or guidance for staff on actions to take to prevent choking risks and what actions to take in the event of a choking emergency. Their medicines support plan recorded that medicines were taken 1 at a time with a glass of drink. However, there was no documented information and guidance relating to the person’s choking risk or that fluids should be thickened. There was no elimination and continence support plan in place despite a catheter being in situ. We could not be assured how staff were supporting the care and management of the catheter and no fluid monitoring records were in place to ensure good hydration and catheter care.

We drew these concerns to the registered manager and provider’s attention who took actions to address our concerns.

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

People told us the environment was clean and well kept. Comments included, “It is absolutely clean. The cleaner who does the bathroom comes in every day”, and “I would say it is very clean. They quickly replace or repair anything that is broken.”

People's bedrooms were personalised to reflect their own interests and preferences. The service provided a dementia-inclusive environment. People had their names and pictures of things that were important to them on their bedroom doors to help aid orientation.

There were sufficient communal areas to aid people’s comfort and for them to enjoy a positive dining experience. There were break out areas for people to sit on their own and or with others, such as family members or friends. There was a secure garden at the back of the service with suitable furniture that people could enjoy in warm weather and a safe balcony on the first floor for people to access.

The service’s maintenance person showed us records from regular audits and safety checks they carried out on equipment used throughout the home. These checks covered maintenance, health and safety, and moving and hoisting equipment. We saw servicing certificates for the fire alarm system, portable appliances, gas safety and legionella testing. We also saw checks were carried out on the call bell system, beds, window restrictors, water temperatures and wheelchairs.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Staffing levels at the service were minimal. The regional director showed us a dependency tool used to determine staffing levels and told us staffing levels were arranged according to the needs of people using the service. People's needs were not always being met because staff deployment did not reflect these needs. We observed there were not enough staff to meet people’s assessed needs working in each area of the building. We noted there was 1 staff on the ground floor and 1 staff on the top floor of the service who were supported by a senior member of staff who floated between these floors. There were 3 care staff and a senior located on the middle floor of the service which was allocated for people living with dementia. We observed 1 of the care staff assigned to the middle floor working on the top floor. This left 2 care staff and 1 senior on the middle floor.

Staff’s views of the staffing levels at the service were mixed. A staff member told us, “Staff levels are okay. There is enough based on the provider’s dependency tool. I work alone with 12 residents; some are independent and some need help. I get support from the senior carer or staff from upstairs if I need help.” Another staff member said, “There are not enough staff to meet people’s needs, we need more staff on the floor. When we raise this with the managers they keep referring to the calculations of the dependency tool. I feel overworked, I feel burnt out. Sometimes bank staff are available but sometimes they are not. They should recruit permanent staff.” A third staff member told us anytime they worked the staffing levels were okay. They told us they were floating on the ground floor and the middle floor. However, we observed them during parts of the day working on the top floor.

People overwhelmingly told us they thought there was not enough staff and staff were busy. A person told us, “I don't think there are enough [staff]. They are so busy and are on their feet the whole time. I think that they could do with more help. The staff that they have seem to be confident. We have had to wait longer if you press the call button, or if they answer they sometimes can’t fulfil the request which is really annoying.” Another person said, “There are definitely not enough staff on any part of this floor. There are not enough carers and not enough catering staff. The carers are also the people who serve the food out. There are no carers when you need one. If I go outside my room and need some help, there are often none about. If there is someone about, sometimes you have to wait a while for someone to attend to you. However, those who are here are wonderful.” A third person commented, “There are not enough on this floor. If you ring the bell after teatime, staff are scarce and it would take a long time for someone to come. When I have had to use the call button the reaction is mixed. They are very busy.” A fourth person told us, “There are definitely not enough staff because you can call people and they don't come for ages. If I use a call button, it takes a long time. They seem to be too busy.”

We drew these concerns to the registered manager and regional director’s attention. On the third day of our onsite assessment, we saw that staffing levels were increased to ensure people’s needs were met in a timely manner.

Robust recruitment procedures were in place. Recruitment records included proof of identification, application forms with employment histories, employment references, health and right to work in the UK checks. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer 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. The service appeared clean throughout and free from odours. The provider employed a team of housekeeping staff to oversee cleaning of the service; we saw them cleaning people’s bedrooms and communal areas.

Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. Training records confirmed that staff had received training on infection control.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. A person told us, “I don't get the medication I need in my view as I can be in pain and need more relief. I do ask for it, but don't get it.” Another person said, “I do have to ask for them [medicines] occasionally. I am a bit of a stickler for getting them on time.”

Medicines were not always managed and administered safely and in line with best practice. Multiple medicines errors were reported to the CQC in November 2025 which involved many people not receiving their medicines as required. These concerns are subject to a safeguarding enquiry led by the local authority. A further reported medicines error was observed during our assessment of the service. We discussed this concern with staff, a visiting healthcare professional, the registered manager, and the provider’s clinical development nurse. Whilst no adverse effects were noted due to the errors this placed people at risk of harm. Following our on-site assessment of the service 2 further medicines errors occurred for which the provider notified us as required. Records we reviewed identified delays in staff reporting medicines errors, delays in staff assessing people’s well-being after missed medication, and poor management and recording of medicines administration charts, failing to ensure these were updated to record missed doses.

A person had a covert medicines support plan in place documenting that they required their medicines to be covertly administered. This means giving medicines in a disguised form without the knowledge or consent of the person receiving them. It may involve hiding medicines in food or drink. We spoke with staff who confirmed that covert administration was no longer required and these records were incorrect. This placed people at risk of receiving unsafe care and treatment. We drew this to the registered manager’s attention who assured us these records would be updated to reflect the person’s current care needs. Whilst we found no evidence that people had been harmed, the provider had failed to ensure the safe management and administration of medicines.

Following a local authority safeguarding professionals meeting with the provider in February 2026, the provider agreed that they would take actions to continue strengthening their medicines governance within the service. This included the implementation of a nighttime medicines verification check. However, when we asked to review these records, we were told that they had not been implemented. We drew this to the regional director’s attention who confirmed that these checks had now commenced.

Medicines were stored securely in locked medicines trolleys and medicine rooms. Controlled drugs were held in a separate locked cabinet with restricted access, in line with legal requirements. Medicines rooms and fridge temperatures for medicine storage were monitored, and staff had received medicines training and had completed up-to-date medicines competency assessments.