Little Hayes

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 safe care and treatment; including management of risk, safe management of medicines, safe environments and infection control; premises and equipment and notification of other incidents.

This service scored 41 (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.

Although some learning events were recorded on the safeguarding log, this information was not always fully completed or sufficiently detailed to demonstrate what learning had been identified or how it would reduce the risk of recurrence. It was not always evident how this information was shared with staff or how learning was embedded into practice. For example, where safeguarding incidents were logged as learning events, records did not clearly show how learning was communicated to staff or monitored for effectiveness.

Team meeting minutes from January, April, July and October 2025 stated that some topics were discussed at length, however, there was limited reference to lessons learned from incidents or concerns, actions agreed, or changes made as a result. This limited assurance that learning from incidents and safeguarding concerns were consistently identified, shared and used to improve practice, potentially placing people at risk of unsafe care.

Feedback from families provided some assurance, with two relatives reporting they felt able to raise concerns. However, delays in reporting incidents to the Local Authority and the CQC, alongside a lack of robust analysis and documentation of lessons learned, increased the risk of repeated incidents and missed opportunities to improve safety

The provider did not always work well with people and healthcare 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.

The provider did not have robust and safe systems in place for people to transition between services. For example, documents to support safe hospital admissions for people did not contain essential information such as, their personal care needs, continence needs, nutritional needs and emotional support. It is important to ensure essential information is shared between services and any risks are known and mitigated. The sharing of this information helps ensure people receive continuity of care in a person-centred way.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

A review of the safeguarding log from January to November 2025 showed inconsistent reporting to the Local Authority and CQC. While some incidents, including altercations between residents, were recorded on the internal safeguarding log, they were not consistently reported to external safeguarding authorities. Other safeguarding concerns, including allegations of abuse, injury, and death were not consistently or sufficiently recorded and were not always reported. Investigations lacked detail, and delays in notifying the local authority and CQC left people exposed to avoidable risk. For example, following a potential abuse allegation in January 2025, the provider conducted an internal investigation but recorded limited information and did not notify the local authority until March 2025 during a care review.

Delays and inconsistent reporting increased the risk of harm and reduced the effectiveness of safeguarding measures.

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

Risks related to people’s care were not effectively managed, exposing them to the risk of avoidable harm. For example, bedrails were observed as being in place however, these did not always have protective bumpers in place or bumpers that fit the full length of the bedrails. This placed people at risk of limb entrapment or injury. We observed 1 person who requires 1-to-1 support was left alone, placing them at risk as staff were not available to monitor their safety or respond to their needs.

Care plans and risk assessments were often incomplete or outdated. For example, there was no detailed care plan or risk assessment in place for someone who had experienced seizures, including the type of seizure, any triggers, action to take and measures to mitigate associated risks, such as bathing. This put them at risk of significant harm through delayed treatment or inappropriate support. Another person’s asthma care plan did not indicate when to seek medical help, putting them at risk of severe harm through delayed treatment. A third person had no specific diabetes care plan or risk assessment in place detailing target blood glucose ranges, signs and symptoms of hyperglycaemia and when to seek medical advice. This put them at significant risk of both short- and long-term harm through unsafe management of blood sugars.

Some people administered their own medicines. Assessments for self-administration of inhalers were not updated following incidents and changes in need, meaning people were at increased risk of over- or under-dosing their medicines. Risk assessments for the management of bleeding risks lacked detail about signs of significant concern which would require medical support. As a result, people were placed at increased risk of preventable harm including unmanaged symptoms, injury and deterioration in health and wellbeing.

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.

Window restrictors were missing or inadequately fitted across multiple areas, including the first-floor lounge, posing a risk to people. On day 1 of our visit on the 10 November 2025, we were informed that new window restrictors had been ordered however no evidence to support this could be provided, the Health, Safety and Facilities Manager gave us limited assurance about how these issues would be addressed in a timely manner. There were several cracked windowpanes, some lacking the safety film, which the provider had previously stated was in place following a previous incident.

Hot, uncovered radiators, exposed pipework, and unguarded heaters placed people at risk of burns, and the laundry room provided unrestricted access to extremely hot water and electrics.

Fire safety arrangements were unsafe, with incomplete fire action signage, doors left unlocked or inadequately secured, obstructed escape routes, and ineffective door gaps that reduced fire resistance.

Hazardous chemicals were left accessible in the unlocked hair salon, and some wardrobes and furniture throughout the home were unsecured and at risk of falling onto people.

Storage areas were cluttered, dirty, and left unlocked, putting people at risk should they fall. Equipment and items were left in corridors and stairwells, obstructing movement and emergency access.

These widespread failures to maintain a safe environment exposed people to serious risks of avoidable harm, including falls from height, burns, unsafe evacuation and injury from unsecured or hazardous items.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

The provider ensured staffing levels were sufficient, and staff received induction, supervision, and most role-specific training. However, staff had not received training in managing seizures, despite an identified need for a service user, which left them unprepared to respond safely in an emergency.

Recruitment processes were robust, including right to work checks and fit and proper persons pre-employment checks for prospective staff.

Although the provider had systems in place to assess and manage the risk of infection, these were not always effective.

The environment was visibly dirty in places. We found a shower chair that was visibly dirty despite a requirement for staff to clean and sign after each use, and windows throughout the hallway were heavily covered in cobwebs and dirt. General waste bags were left outside a bedroom, and bathroom equipment, including a jug, the bath, the bath hoist and its footplate was stained, rusty or visibly unclean.

Furniture in the first-floor lounge was dirty, including an armchair with a large tear, and a cushion in the laundry room was stained with faeces. Limescale and scale had built up around taps, plugholes and sinks, indicating poor routine cleaning, and first aid supplies in the hair salon were significantly out of date.

Colour coded mop heads were stored together in a dirty bucket in the laundry room and cleaning schedules contained gaps, showing that essential cleaning tasks were not consistently recorded, increasing the risk of cross-infection. The service could not demonstrate effective infection prevention and control practices.

Recent infection, prevention and control audits did not identify all concerns found during this inspection. These failings increased the risk of cross-contamination, spread of bacteria and infection, and left people vulnerable to illness, delayed treatment and unsafe standards of hygiene.

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

We identified significant shortfalls in the management of medicines including safe storage.This demonstrated that the provider did not ensure the safe and proper management of medicines, exposing people to risks of untreated symptoms, overdose, deterioration, or hospital admission.

On day 1 of the inspection, we observed both windows in the medicines room did not have safety measures in place to prevent access from the outside. Both windows were able to open fully, and medicines were stored in cabinets which were unlocked. Keys to a medicine trolley were visible and hung up on a notice board, the key to the controlled drugs cabinet was kept in the trolley. This was immediately raised to the management team. Later the same day the medicines room was found unlocked. On day 2 of the inspection, whilst the management team were implementing security of the medicines, we observed the keys continued to be hung on the notice board and the medicines cabinet remained unlocked and open. This meant people, staff or visitors could access the medicines inappropriately.

Controlled drugs (CD) were not safely managed. Records were not kept in line with regulations, which are medicines which are subject to strict legal guidelines around their use. From review of the controlled drugs register we identified that the register was not fully completed, the formulation was not entered with the medicines name, doses were not always fully recorded, and the index page was not up to date. The records also showed that some administrations or auditing entries were completed by only one member of staff and not witnessed. Furthermore, the signing out of controlled drugs was not completed correctly, this made the CD register look like CD's were still in the building when they were not.

The CD register evidenced that a transdermal pain relief patch for a person had not always been applied as per the prescriber’s instructions, which was every 7 days. We identified two occasions when this was applied 7 days and 5 days late. This meant the person went without there prescribed pain relief for this period of time. Furthermore, the body map in place demonstrated that the patch was not rotated between sites on the body in line with prescriber’s guidance. The lack of rotation could lead to an increase in adverse reactions or potential overdose of a medicine.

Some people were prescribed 'as needed' (PRN) medicines, which require clear protocols for their use. Guidance in the form of protocols or care plans were not always in place; maximum doses conflicted with the prescriber’s instructions and care plans were not always person centred or individualised. This meant the provider could not assure themselves PRN medicines were administered consistently. These included medicines prescribed for people’s heart conditions, respiratory conditions and severe allergies. Some PRN protocols we reviewed contained incorrect information about people's allergies.

A PRN protocol for a person’s EpiPen did not detail signs, symptoms, when to administer, or when further doses may be required. PRN protocols for people who were prescribed medicinal sprays for angina did not specify when to administer, how frequently, or when to seek emergency help in line with NHS guidance. People in need of pain relief or at risk of constipation had no clear PRN protocols, leaving staff without guidance to assess need or recognise deterioration.