Thomas Edward Mitton House

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 inspection we rated this key question requires improvement. At this inspection, the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service is in breach of legal regulations related to safeguarding, safe care and treatment and staffing. Safeguarding concerns and incidents were not always well documented or managed. Care plans did not contain enough information on managing risks. Staff competence to support people was not being checked effectively to make sure they could support people safely.

This service scored 34 (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.

Incidents at the service were reported by staff and reviewed by the management team. However, actions taken as a result of these incidents were not clear and were not followed up to help promote a learning culture. Often incident actions were recorded as ‘managed in service’ when the incident indicated there were opportunities for investigation and learning. For example, if people were found not to be safe using a piece of equipment or people were found to be eating food that was unsafe for them because of their dietary needs. Incidents were not discussed with staff to help lessons be learned. A relative told us, ‘‘We have raised concerns about the way incidents are handled. There never seems to be an understanding of how important it is to us that staff learn how to do things more safely.’’

The service manager and regional manager were responsive to our findings and retrospectively reviewed incidents for any learning. One person said, ‘‘If something needs to change then [staff] will change it.’’

The provider did not consistently work well with people and health system partners to establish and maintain safe systems of care. They did not effectively manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s needs were not adequately assessed when they transitioned to the service from places such as hospitals. Care plans produced as a result lacked detail for staff to support people safely. When people needed to use other services such as hospitals, limited information was available to other professionals about how best to support them with their needs. People’s rehabilitation was not effectively monitored whilst they used the service to help ensure they were able to transition back home safely. One relative said, ‘‘We have seen very little improvement in relation to [family member’s rehabilitation] and we are worried about the lack of progress.’’

The service manager and regional manager were responsive to our findings. They showed us how they would improve the admissions and transition process for people. One person said, ‘‘[Health professional] comes in every few days but [staff] would help me see someone external if I needed to.’’

The provider did not work well with people and partners to help ensure their safety. The provider did not always share concerns quickly and appropriately.

We identified several incidents that had happened at the service, which had not been reported as a safeguarding event to the local authority. This put people at risk as potential abuse was not being independently investigated. The service manager completed these referrals retrospectively. Staff did not always support people in line with their care plans. For example, staff did not intervene when a person tried to put too much food in their mouth to prevent a choking incident. One relative said, ‘‘I am not assured [family member] is safe. I always seem to need to remind staff how to do things.’’

People and some relatives told us they or their family member were safe using the service. One person said, ‘‘I feel safe and there is never any trouble here.’’

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 had care plans and risk assessments in place for support needs such as being supported to walk, eating and drinking and specific support needs. However, these were of poor quality and did not contain detail to help guide staff how to support people and mitigate risks. For example, care plans would identify a person needed a piece of equipment to mobilise safely. However, it would not detail how staff were to support them to use this. Care plans about how to support people with personal care did not detail how staff could help people to do this safely. Care plans in relation to eating and drinking stated people needed specific diets to stay safe. However, they did not detail how staff could prepare these diets to make sure people were safe. People and relatives were not being asked to discuss care plans and risk assessments. One relative said, ‘‘I’ve never seen a care plan since [family member] has lived at the service. We have an annual meeting and that is it.’’

The service manager and regional manager were responsive to our findings. They showed us how they would improve and update people’s care plans and risk assessments to make them more detailed. One person said, ‘‘[Staff] know how to use [equipment] to help me get around.’’

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Several areas of the environment such as window locks and some areas of the floor were not safe or secure when we first visited the service. There had also been ongoing problems with the heating system at the service. There were areas of improvement needed to the environment such as changes to flooring and the heating system that had been known to the provider since 2022 or 2025 but had not been actioned yet. The majority of these issues were rectified or started to be rectified during our inspection.

Other areas of the environment, including in relation to fire safety were safe. Staff completed regular checks to help make sure this was the case. One person said, ‘‘It is a nice set up here. [Staff] turn on the fire alarms so we can practice leaving sometimes.’’

The provider did not make sure staff were qualified, skilled and experienced. They did not always make sure staff received effective support, supervision and development. They did not consistently work well together well to provide safe care that met people’s individual needs.

Staff had training to support people in areas such as moving and handling, eating and drinking safely and specific support needs such as catheter care. However, we were not shown evidence this training was being checked to help make sure it had been effective. For example, training was not being discussed with staff and checks on their competency after their training were not being completed. We could not be assured training had been effective as a result. A relative said, ‘‘[Staff] do not understand [family member’s] needs. I know they have the training, but I do not think this is put into practice. They do the basics but nothing more than that.’’

We received mixed feedback from staff about staffing levels. Staff told us staffing numbers were based on number of people using the service rather than what their support needs were. This limited the opportunity for them to spend meaningful time with people as they were busy helping them with essential support needs like personal care. However, we saw there were enough staff to support people safely. Despite this, we observed people to go for long periods of time without interaction or engagement. A relative told us, ‘‘[Staff] always seem so busy but never in a rush. [Family member] has to wait longer than what they should when they need to use the toilet.’’

People and some relatives were more positive about staffing. One person said, ‘‘If you want a staff member to talk with then they will do.’’ A relative told us, ‘‘There has always been a big turnover and change of staff at the service but there has always been enough staff around.’’ The provider recruited staff safely in line with legislation.

The provider did not always assess or manage the risk of infection. Several areas of the service were not clean. These included areas of the kitchen, the communal ‘games room’ at the service and several areas where cobwebs and dust had visibly built up. These areas were cleaned during our inspection.

We observed the rest of the service to be visibly clean. Audits and checks were in place to monitor the cleanliness of the service and the effectiveness of the IPC measures in place. A person told us, ‘‘I have no problems with how clean staff keep the place.’’

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

People were prescribed medicines that were to be taken on an ‘as and when required’ (PRN) basis. However, protocols and guidance for staff about how and when to administer these to people were not in place. This put people at risk of these medicines not being administered correctly. People and relatives were not asked to be involved in discussions and reviews about their medicines.

However, staff administered medicines to people safely in line with their preferences. Checks and audits were effective in making sure medicine stock levels were correct. Medicines were disposed of correctly where necessary. One relative told us, ‘‘[Family member] has a lot of medicines and managing these must be complex and not at all easy. It is good I can trust the staff completely with these.’’