Mentaur Community Support Limited

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 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

There was evidence of routine processes such as daily handovers, induction records, and regular supervisions. Meeting minutes were available and incident records were reviewed. However, themes were only analysed during 6 monthly audits. The management acknowledged this gap and agreed to increase the frequency of thematic reviews. An action plan was in place and was updated with our findings during this assessment.

People and their relatives told us they knew how to make a complaint and were confident to do so. One family member told us, "Not raised any concerns. If (relative) has to go to the doctors, they call us. If (relative) complains about a resident we can speak to the management. They will support us."

However, we were not assured of consistent learning across the service. Issues previously highlighted through provider audits and spot checks such as undated creams and nasal sprays and insufficient detail within care notes were identified again during this assessment. This indicates that learning from concerns and audit findings were not yet embedded consistently across the team.

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 had hospital passports in place, although these could be strengthened by clearly documenting whether a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision was in place. One relative told us,"(Person) was taken into hospital and they put the DNR in. The manager told me. We complained” Another said, "We were involved. We had meetings to discuss what support (person) needed. We go to the hospital with (person), we know their history. I also have a hospital passport and can stay with them". Staff demonstrated awareness of health-related risks and made referrals to health professionals and social care professionals. They supported people to attend appointments. Systems were in place to ensure smooth transitions between services. The registered manager told us the service routinely met people before they started, encouraged visits and promoted the use of existing communication tools to support good transitions.

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.

People appeared relaxed and comfortable around staff, and regular contact with family was mostly maintained through visits and time spent at home. Court of protection orders were in place where required to ensure decisions were made lawfully in people's best interest.

People and their relatives told us they felt safe. One relative told us, "Yes, they are safe. When I take them on holiday, they want to come back after a couple of days."

Staff were able to describe how they would identify and report concerns, including escalation to the local authority safeguarding team or the police. They knew how to access the whistleblowing policy and felt confident to raise concerns. Staff had received appropriate safeguarding training.

Systems were in place to identify, report and respond to abuse or neglect were in place and understood by staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Positive behavior support (PBS) plans and risk assessments were in place, including those for falls and epilepsy. However, risk assessments were not in place for those using flammable creams, this was discussed during this assessment. This was put in place on 5 March 2026.

We could not be assured people were protected from the risk of burns or scalds, as water temperatures were not checked and carer notes did not evidence that water safety checks had taken place. However there had not been any incidents of burns or scalds.

Staff told us they knew how to access risk assessments and felt they contained enough information, but people were not routinely involved in reviewing their own risks. There was limited evidence to show how people were supported to take part in discussions or decision making.

Staff had received PBS training and supported people to take positive risks; however, improvements were needed to ensure all people were fully enabled to reach their full potential.

People and their relatives told us they felt the service managed risks well. One relative told us,"(Person) has epilepsy. There is a good night carer that looks out for them. "Another said, "Yes, they are aware of (person’s) risk of falling. Also, their oxygen levels can fall. They do deal effectively, if this occurs. They know when to call the emergency services.”

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.

Fire safety assessments and Personal Emergency Evacuation plans (PEEP) were in place.

Compliance checks for gas, electricity and legionella were up to date, and records showed regular fire alarm testing and drills. During this assessment, we identified an electrical cupboard containing packaging and other items. Although this had been identified through fire risk assessments in July 2025, the cupboard was not cleared until the time of this assessment. We observed a broken personal fridge door which presented a potential safety risk. This was replaced during this assessment.

People's rooms were personalised. However, aspects of the shared environment were not well maintained. A lounge window had no curtain, although the registered manager (RM) told us this

had been ordered. Carpets, sofas and chairs were worn, dirty and ripped. The RM initially advised that people needed to agree to replacements, but our review of tenancy agreements confirmed these items were covered by the service charge. The RM later informed us that the landlord had agreed to address these issues.

The providers’ systems to ensure a safe, well- maintained person-centred environment were not consistently effective. As a result, people were not always supported to live in surroundings that

promoted their well-being.

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.

Staff were supported through regular one-to-one supervisions meetings. Recruitment processes were safe and followed required checks.

Staff had completed training, including Positive Behaviour Support and Learning Disabilities, but there were gaps in other required training. The management team were aware of these and described plans to address them.

We identified that staff were carrying out blood pressure monitoring and pulse readings without having received the appropriate training. Training was booked during this assessment;

however, this gap had not been identified through provider audits.

Despite these issues, we observed positive engagement and interactions between staff and people throughout this assessment.

Staff told us they were sometimes short of staff. One family member told us,” They have a large turnover of staff.”

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.

Staff told us they had access to PPE and had received training in infection control.

We identified several concerns with the cleanliness and maintenance of the environment. A shared bathroom was visibly dirty, including skirting boards and shower curtains. The curtains

were replaced during this assessment, and the management team have assured us a deep clean has been carried out. The bathroom also had mould and flaking ceiling paint. The management team told us this was a recurring issue; this was addressed during this assessment. The extractor fans in the kitchen had not been cleaned, these were cleaned during this assessment and added to the cleaning schedule. Kitchen cupboards were also found to be dirty. A personal fridge belonging to one person had a broken door. Although this was replaced during this assessment fridge temperatures had not been monitored, meaning that there was no assurance food was being stored safely.

People and their relatives told us areas were clean. One person told us, "It is clean and hygienic. They wear gloves when carrying out personal care.”

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

Medicines audits were completed and included identified actions; however, they did not identify all the issues we found during this assessment. New audit templates were put in place during

this assessment.

Medicines storage temperatures were recorded, but the forms did not include guidance on acceptable temperature ranges or actions to be taken when out of range. This was updated

during this assessment.

Records we reviewed showed people were receiving their medicines safely, surplus medicines were returned to the pharmacy. Medicines Administration Records (MAR) clearly recorded

reasons for gaps, such as when a person was on social leave.

PRN (as-required medicine) protocols required further details, including how people communicated their need for medicine and when staff should contact GP.

Some topical creams and sprays did not have opening dates recorded, despite this having been identified through monitoring.

People and their relative’s mostly felt medicines were managed safely. One relative told us, “Only once there was an incident. A carer gave (person) someone's medication. They had a review meeting.” Another said, “No problems with medication.