Temple Ewell Nursing 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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, staff recruitment, safeguarding and staff training.

This service scored 38 (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. Accidents and incidents had been recorded, however, there was limited analysis of the underlying causes and factors which could have contributed, to identify any patterns and trends.

Root cause analysis (RCA) forms had been completed following an incident or accident. We reviewed a sample of these and found the completion of these had not been used as a learning process to reduce the risk of the incident happening again. For example, a person had become distressed and had been physically aggressive towards staff. The root cause had been given as ‘Dementia-related confusion and distress leading to defensive behaviour when redirected.’ There was no investigation into what had happened immediately before the incident, how the staff had supported the person and if there was a pattern of distress. The section for learning identified had been completed with ‘Resident settled; staff injury managed; ongoing monitoring in place.’ The person continued to have incidents of distress for the next 2 months before our inspection. We reviewed the person’s care plan there was no person centred guidance for staff about how to recognise triggers and how to de-escalate episodes of distress. The care plan focused on actions to take once distress had occurred, there was a risk the incidents would keep happening.

The registered manager completed a monthly review of incidents and falls. We reviewed the 3 months before the inspection; the reviews had not been used to identify patterns or learning to make improvements. In March 2026, there had been 2 choking incidents and 2 incidents of distress, the overview stated, ‘The review confirms that each incident can be attributed to identifiable factors linked to residents’ clinical needs and behavioural presentation, rather than any systemic concerns.’ The conclusion stated, ‘The service has demonstrated appropriate oversight, learning and adaptation of care, ensuring risks are minimised while maintaining a safe and person-centred environment.’ However, there was no evidence how this had been put into practice. People’s care plans had not been reviewed or changed following the incidents. There was no evidence staff had been involved in the process to reflect on what had happened.

There was a culture of acceptance incidents and accidents would happen due to people’s health conditions. The management team had missed opportunities to develop person centred support to reduce the incidents and accidents people experienced.

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

Some people had been admitted to the service as an emergency for a short period, due to the breakdown of their previous placement. People’s needs were not always within the staff skillset to manage and required input from specialist teams. People had not been moved to a more appropriate placement quickly. The management team had not actively sought support from specialist community learning disability teams to either provide specialist training for staff, help them develop support strategies or to find an appropriate placement. For example, positive behaviour support plans to manage distressed behaviour including self-harming. People had lived at the service for a long time without the same access to specialist support they would have access to if they were living at a specialised service.

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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. The registered manager and the clinical lead had not recognised potential safeguarding concerns or their responsibility to report these concerns. We reviewed the wound summary for December 2025; there had been 6 incidents of unexplained bruising including to people’s arms and wrists.These had not been assessed as to the potential cause and if the bruises should be reported to the local safeguarding authority for investigation.

Some people had developed blisters on their heels and shins; others had developed deep pressure areas. These wounds had not been investigated to identify how they had happened, identify any patterns and if staff required additional training. The registered manager had not acted to protect people from avoidable harm.

Staff described signs they would look for to identify potential abuse and how to raise concerns. However, when a person developed a sore groin, the person expressed concern about how staff moved them. Staff had not followed correct moving and handling guidance. Staff had not recognised this as a safeguarding concern and no staff had raised a concern.

The service had made Deprivation of Liberty (DoLS) applications to the local authority to deprive some people of their liberty. This is a necessary legal procedure to follow when a person who lacks capacity to consent to their care and treatment requires restrictions in order to keep them safe from 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. Potential risks to people’s health and wellbeing had not always been risk assessed and there was not detailed guidance to mitigate the risks. One person had been admitted to the service in September 2025, however, a comprehensive care plan had not been written until March 2026. During this time staff did not have access to detailed guidance to reduce risks.

We reviewed 4 care plans where people had been living at the service for at least a year, who did not have risk assessments or clear guidance for staff to meet their complex needs including the use of bedrails, epileptic seizures and oxygen use. We discussed this with the registered manager, who put some risk assessments in place, however, care plans had not been updated.

Staff did not have detailed guidance to move people safely. People’s care plans stated people should be moved using a hoist and sling or 2 slide sheets. There was no information about which sling to use and how to position it, this was essential when people had a limb weakness or amputation, to make sure they were moved safely. One person’s care plan had contradictory information, guidance stated they could stand with 2 staff but also were immobile. There was no guidance for staff about how they should support the person if they were supporting them to stand.

Some people were at high risk of skin damage or already had wounds. They were being nursed on pressure relieving mattresses, some of these were required to be set according to the weight of the person to be effective. We found 4 people’s mattresses were not set to the correct weight, all the people involved had wounds some of which had developed in the service. Care staff had recorded the mattresses had been checked on the electronic care plan. We discussed with the registered manager what system was in place to check staff were completing the checks accurately, they told us there was no system. People’s care plans did not always identify specific risks to people’s skin integrity. For example, a person often shuffled on their bottom across the floor, this had not been identified as a specific risk to their skin and there was no guidance about how to reduce the risk.

Some people were at risk of choking and had specific speech and language guidance to make sure they ate their food safely. Care plans did not always include accurate information, for example, a care plan stated a person could have yogurt, but it did not include the instructions to ensure the person ate safely.

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. There were systems in place to evacuate people. However,potential risks to people’s health and wellbeing had not been considered when people were on the floor such as their skin integrity and not being able to sit up.

There were personal emergency evacuation plans (PEEP) in place, but these did not contain detailed guidance on the support people needed. People’s specific needs had not been assessed. For example, a person had been assessed as mobile, however, it had not been considered how far they would have to walk or the fact they required constant oxygen. Staff had not considered how an emergency such as a fire would impact on the person and the additional support, they would need to be safe.

We checked the ‘grab bag’ which would be given to emergency services during an evacuation. The information was not accurate; we found 3 people were not on the summary sheet and did not have a PEEP in place and another PEEP had the wrong person’s name on it. The summary sheet did not reflect people’s needs, for example, people were given scores meaning they were mobile with a walking frame when they were immobile. A member of the management team had signed off the documents as being accurate the week before our onsite visit.

Following our onsite visit, we requested an immediate review of the PEEPs in place and evacuation plan. Following our onsite visit, we received updated PEEPS, confirmation evacuation sheets to go under people’s mattresses had been put in place and dates of staff training to use the new equipment.

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 work together well to provide safe care that met people’s individual needs. Staff had not always been recruited safely, the systems in place had not ensured all the required checks and information were in place. The provider had not obtained a full employment history for staff, the application form used asked for only 10 years of employment history. We reviewed 2 recruitment records; the dates of employment had not always been obtained to identify any gaps in employment. References had not been sought from all previous social care employment to check conduct. When references had been received, it had not always been checked when the dates of employment had not been completed or did not match those given by staff.

There were no systems in place to make sure nurses received clinical supervision to discuss their clinical practice and identify any training needs. The clinical lead told us there were group supervisions at lunchtime when the nurses and nurse associates met to discuss people’s clinical needs. However, these meetings did not include nurses who worked on nights and had not been recorded to show what had been discussed.

Staff received a mixture of training including face to face and online courses. However, some people had complex needs such as autism, a learning disability or dementia needs. Staff had received awareness training but there had been no assessment to make sure the training gave staff the skills they needed to meet people’s needs. Staff received supervision twice a year and an appraisal but there was no evidence to show if they had discussed if they were confident to support people with these complex needs.

Staffing levels were calculated using a dependency tool. We reviewed the duty rotas and found there was the recommended number of staff on duty. Staff told us they thought there were enough staff and they could support people as they wanted. Relatives told us they thought there was enough staff, but they were busy all the time.

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. We observed there were areas where infection control guidance had not always been followed. There were pedal bins in communal bathrooms which did not have lids, or the pedal did not work, this did not support no touch disposal. There were some areas such as showerheads which had limescale present. We reviewed the shower head and hose cleaning record, showed the cleaning had last been completed in February 2026. These areas had been identified during a mock inspection completed in March 2026 and continued at the onsite visit. We could not be assured the cleaning process was effective or shortfalls identified.

Staff had received infection control training. We observed staff wearing gloves and aprons appropriately when supporting people.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were not always managed safely. We could not be assured staff were following the correct processes to administer and record controlled medicines which had additional requirements. These medicines require 2 staff to be present and sign the register after the medicine had been given. However, records showed staff had not always followed the provider’s protocol. For example, a pain patch which had not been given had been written in the register. Staff had signed to confirm they had witnessed it being given, which had not happened, the records were not accurate. When a medicines box had been damaged and could no longer be used, staff had left the tablets in the storage cupboard with no information about who they belonged to and had not informed other staff what had happened. This did not follow the correct procedure to ensure the tablets were accounted for. The medicines audit had identified these incidents had happened, but there was no action plan to check staff were completing the process correctly.

Some people had medicines prescribed on a ‘when required’ basis. There was guidance in place for staff about when and how much medicine to give, however, this guidance was not always up to date and accurate. The guidance had not been updated when the instructions from the GP had changed. There was a risk people would not receive their medicines as prescribed.