Dickley Court

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.

The service was in breach of legal regulation in relation to people’s safe care and treatment, medicines management and infection control risks.

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. Lessons were learnt to continually identify and embed good practice.

Analysis had been carried out by the management team to determine the root cause of incidents and actions were taken to prevent things happening again. Where incidents had occurred the staff team had discussed the incident and reviewed what had happened. They looked at what the triggers could have been and how they might work differently with the person in the future. A staff member said, “We haven’t had lessons learnt meetings but the managers feed back when we need to change how we do things.”

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.

The provider used an electronic care planning system and people’s care plans and risk assessments were on this system. Hard copies of care plans and risk assessments were stored in people’s homes. The electronic system enabled the staff team to create hospital passports when these were needed. A hospital passport helps people to give hospital staff and other services important information about them and their health when they go to hospital. A director told us, hard copies of hospital passports were in place in their homes.

Before people received support from the service, they had an assessment to check with them and their relatives what their care and support needs were. People were then offered short visits to view shared houses, to see if they would like it. They were given the opportunity to visit the service for a day and not staying the night, visiting for dinner and also meeting other people they might be living with. Only when people were comfortable, they moved in and were supported through a robust transition. A relative told us, “They know him very, very well, he’s had a gradual transition over a long period, spends 5 days per week there and 2 days with us. There has been no hiccups in transition.” Another relative said, “When a new person moved in, they did it gradually, dinner, games night and a 1-night stay. They were involved in making the decision if the person could move in.”

People were supported to maintain their health. Routine health checks were undertaken. If people became unwell, staff supported people to gain medical support.

The service had maintained regular contact with local authority social workers and other health and social care professionals. This included ongoing work with people’s GPs. Staff told us they were able to contact the GP if people became unwell. A staff member told us, “[Person] is regularly supported to go to the GP, I have taken her 3 times in the recent weeks.”

A relative said, “They supported him recently to see the dentist, his health is very well monitored. They are very good about informing me, they feel he has a possible allergy with ears, nose and throat, they have been taking him to the doctor about this.” Another relative told us, “They are supportive of hospital visits, and they are good at communicating.”

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. The provider shared concerns quickly and appropriately.

People were safe and were protected from harm. We observed interactions between staff and people during our visits. We saw safe practice whilst enabling people to maintain their routines and come and go as they wanted. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff told us they were confident to speak up if needed. A staff member said, “I would report abuse to my supervisor and manager. My manager would handle it the correct way. She would also talk to the service user, I would report to CQC.” Another staff member told us, “I would report abuse to my manager and or the police and social services. It would definitely be dealt with.”

People told us they felt safe. A person said, “I feel safe living here.” Another person told us, “I feel safe, because people are here.”

Safeguarding policies included information about safeguarding children from abuse. Safeguarding training included safeguarding children. This is because staff in care services come into contact with children as part of their work.

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.

Risk assessments were not always detailed or robust. For example, people’s epilepsy risk assessments had not fully explored the risks and actions to mitigate risks such as falls, injuries (including burns from falling against uncovered radiators), choking, drowning and SUDEP (Sudden Unexpected Death in Epilepsy). People had positive behaviour support risk assessments in place. These showed that some people could become distressed and anxious which could cause injury to themselves, others or staff. Their risk assessments did not detail safe ways of working and provide information to staff on how to work with the person when they had reached crisis. Infection control risks were not clear in care plans and risk assessments.

Personal emergency evacuation plans (PEEPs) were not always in place to detail people’s support needs if they required to be evacuated in an emergency. PEEPS that were in place did not include risks to people who were prescribed flammable creams. There had been no assessment of risk to tumble drying clothing, bedding and towels which had been used by people using flammable creams. The registered manager updated PEEPs regarding this and put a risk assessment in place regarding tumble driers after our visits to the supported living houses.

Staff told us about safe ways of working with people which demonstrated they knew them well.

Relatives told us they had been contacted when there had been incidents and accidents and actions had been taken. A relative said, “They are good at communicating.”

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. The provider had not always carried out assessments to check that each property was a safe environment for people. For example, risk assessments had not been undertaken to check if window restrictors on the upper windows were required. We reported this to the management team and provided them Health and Safety Executive guidance in relation to falls from heights.

We also observed radiators without covers in some supported living properties, this meant people were at risk of harm from burns from hot pipes and surfaces. The service provided care and support for some people who were at higher risks of burning themselves through falling against radiators and pipes, as some people had a diagnosis of epilepsy. We gave the management team Health and Safety Executive guidance in relation to ‘managing the risks from hot water and surfaces in health and social care’. In a supported living house, we found a damaged tile on the floor in the bathroom which was sharp to touch and could cause injury. The management team told us this had been reported to the landlord on 1 December 2025. We visited the property on 17 December 2025, and no action had been taken to mitigate the risk of injury. A staff member said, “Anything broken or tatty gets raised, most of the time it takes a long time to get fixed, or it doesn’t get done. The sink on the island in the kitchen has been blocked for months and awaiting repair.”

The providers maintenance team worked within Dickley Court short breaks service and within the supported living properties. In some of the supported living services we visited we found that the communal areas had tired and tatty paintwork, carpets required replacing due to wear, holes and ripples which were trip hazards. This work was the responsibility of the landlord (some properties were owned by the provider Symbol Family Support Services Limited). Staff told us they had reported maintenance concerns to the registered manager, who escalated these to the provider, landlord and maintenance team. Staff told us action was not always taken in a timely manner to address these issues. Several staff at one supported living house told us the damaged tile we observed during the assessment had been like it for many months. A staff member said, “The damaged tile in the bathroom has been like it for ever, there was a piece of pipe sticking out of the floor in [person’s] room, but I believe that has now been removed.”

A relative told us, “It’s tired and could do with a lick of paint in communal areas. The carpet in the hallway needs replacing, it is like an old pub carpet. The window is tatty is [person’s] room.”

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

Most staff had completed mandatory training to meet people’s needs. Some newer staff had not completed all of their training courses but were working towards this. Some staff told us they had not done Makaton training despite providing support for people who use this to communicate. The provider’s training records confirmed that staff had not completed Makaton training. A staff member said, “[Person] uses Makaton and [person and person] did. We have not been given Makaton training.” Staff said, “We do mandatory training online and also go to the office to do training, which was medical based heart defibrillator, seizures, epi pen. We do moving and handling online, as there is no one at the house that has moving and handling” and “I did lots of training before in my old job and had to redo it. They are hot on training.” A director for the service told us, "We have people within our services that use their own personalised version of Makaton to communicate, while formal Makaton training for staff may be beneficial, it is not essential for effective communication, as staff who work directly with each person have developed a clear understanding of their individual sign, gestures and meaning. This is covered as part of staff members inductions into the service. Their inductions and shadow work are tailored to the clients they will be supporting."

Some staff had regular supervision meetings, induction was a mixture of training and shadowing experienced staff to gain confidence and experience.

We observed there were enough staff on duty to support people. Staff had been safely recruited. All required checks had been carried out, and documents were all in-date. The information helps employers make safer recruitment decisions.

Relatives told us there were enough staff and the consistency of staff met their loved ones needs. Comments included, “There are most definitely enough staff”; “I think there’s enough staff”; “There is a fairly slow turnover of staff, most staff know him very well” and “There is always enough staff and they are really good.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. People were supported to clean their own rooms; people told us they did these jobs on their home days. Some people were independent with these tasks and others needed more support and guidance. At different supported living properties, different arrangements were in place for communal cleaning of shared spaces. The care staff carried out some daily cleaning and people and care staff carried out other cleaning. The provider had responsibility for communal areas in the supported living properties. We observed some bins around the service which increased the risk of cross infection as they did not have suitable lids or foot pedals/sensors. In 2 of the 3 supported living properties we visited, we found that communal areas were not clean. In 1 of the houses, a shower room and toilet had a very strong odour of stale urine and the flooring around the toilet was discoloured and stained. In the other house, there was a very strong smell in the hallway and bottom of the stairs. Whilst staff had reported these issues, timely action had not been taken by the provider and the provider’s maintenance team to address them. A staff member told us this smell was always present. A health and social care professional told us, “On my recent visit noted a smell of urine, which I highlighted to the team manager.”

The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. We observed that the staff were using PPE effectively and safely. Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. A staff member told us, “100% we have enough PPE.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found systems to record medicines were not always effective. Medicines risk assessments did not always provide all the information staff needed to provide safe care and support. For example, some people were prescribed Levothyroxine, this medicine should be taken 30 minutes before food and caffeinated drinks, because these interfere with how Levothyroxine works. The medicines risk assessments did not provide staff this information, which put people at risk.

At 1 of the supported living properties, we found expired medicines in stock in a person’s medicines cabinet. Some medicines found in people’s cabinets were not listed on the medicines administration records (MAR). Some MAR charts did not match with the prescription labels. A list of prescribed medicines were not listed in people’s medicines care plans to detail what was prescribed and why. This meant that medicines may not be known to emergency health professionals because the medicines information would not populate on the hospital passport if this was downloaded using the electronic system. A director for the service told us hard copies of the hospital passport were in place and used alongside the MAR if a person required a hospital appointment. We found topical medicines charts for creams and lotions did not always show staff where the cream needed to be applied. Some people were prescribed medicines to be taken only when required known as (PRN) medicines. Guidance (PRN protocols) were in place for most people to help staff give these medicines consistently, a person’s PRN protocol for pain relief was not in place.

We reported these issues to the management team; the registered manager told us they had taken action to update medicines risk assessments after the assessment.

Medicines were securely stored and timed medicines were given appropriately. People had their own secure medicines storage in their own bedrooms. People were supported to order and collect their own medicines.

Staff told us they received medicines training and training records verified this. Staff said, “We are all medicines trained and we have competency checks every couple of years”; “Medicines competency checks are completed, I give medicines all the time. If a medicines error happens, I have to report it to my manager” and “They wouldn’t let you give medicines without competency checks, they are hot on this. There is guidance in place in case of medicines errors. I would phone 111, get advice and write a medicines error report. If this happened, I would have to do the medicines competency again.”

People told us they received their medicines when they needed them. Comments included, “Staff give me medicines. Sometimes I have support with putting in repeat prescriptions. I go and collect it from the pharmacy on my home day” and “Staff give me paracetamol if I get a headache, staff give me my medicines every day.”