Dalemain 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 assessment we rated this key question requires improvement. At this assessment the rating has remained 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 provider was in breach of legal regulation in relation to people’s safe care and treatment.

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.

For example, several incident forms we reviewed contained blank sections, including recommendations to avoid similar incidents occurring in future and follow up actions, and had not been reviewed by senior staff. We found no evidence of shared learning or staff debriefs following incidents. Team and staff meetings did not include any documented shared learning. Staff we spoke with confirmed they did not receive debriefs following incidents.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

For example, pre-admission assessments were completed by email or telephone, with no evidence people or their families were involved in the process. One family member raised concerns about their relative’s admission to the home, as there had been no welcome pack, introduction, or involvement in care planning.

However, the provider did obtain input from other healthcare professionals, such as social worker’s and GPs, to gather information about people’s support and healthcare needs.

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.

For example, a review of accidents and incidents showed one person had 12 falls between January and April 2025. However, no effective internal analysis was completed to identify trends and causes to prevent further falls. We identified some accidents, incidents, and safeguarding concerns had not been reported to CQC when required. We raised this with the manager and we clarified which incidents must be reported to CQC and which required a safeguarding referral.

Staff had completed training in safeguarding and were able to identify signs of abuse. People told us they felt safe. One person told us, “I am looked after and safe.”

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.

For example, Personal Emergency Evacuation Plans (PEEPs) lacked essential information. Some PEEPs did not include details about people’s health conditions, level of understanding, or support they would need to evacuate. This placed people at risk of not being evacuated safely in an emergency.

Risk assessments and care plans were not always updated to reflect people’s current needs. For example, a falls risk assessment for one person failed to include one of their diagnosed conditions. This demonstrated a failure to consider known medical conditions when assessing risk, providing an inaccurate picture of the level of risk and risk management strategies required.

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. For example, furniture in people’s bedrooms was not secured to walls, creating a significant risk of injury if it fell. We identified broken windows and missing window restrictors. We raised this with the manager, and the issues have since been resolved.

We identified fire safety concerns including fire doors not closing fully into rebate, PEEPs did not reflect accurate staffing levels, a lack of risk assessments for flammable creams, and no recorded fire drills or evacuations. Staff spoken with had not been part of a fire drill or evacuation. We referred these concerns to Merseyside Fire and Rescue service.

In addition, people had unrestricted access to high-risk areas such as the basement and kitchen because the entry codes were visibly displayed on stickers above the locks. The basement contained an unguarded flight of stairs, which posed a risk of falls from height, as well as access to hazardous substances such as cleaning chemicals and paints. We raised these concerns with the manager, and they were addressed immediately.

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.

For example, staff had completed mandatory online training but had not received any face to face training in key areas such as practical moving and handling. Most staff had not had their competencies assessed in line with current best practice, providing no assurance they were competent to carry out their roles. The manager confirmed she observed staff practice but had not recorded these observations.

Some staff felt their training was sufficient, while others felt they would benefit from more face to face training in specific areas.

Although, most staff had recorded supervisions, none had received annual appraisal.

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.

At the time of the assessment, there had been a COVID-19 outbreak, which resulted in some people being isolated in their bedrooms. Appropriate risk assessments were in place, policies were followed, and families and local authority had been notified. However, CQC had not been notified about the outbreak, so we were unaware of it when we attended the home. There was signage on the main door alerting visitors to the outbreak. PPE was available throughout the home, but we observed it being disposed of incorrectly, increasing the risk of cross-contamination.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. For example, we identified patterns where some people who were prescribed particular pain relieving ‘when required’ medications were being administered frequently, without evidence of appropriate referrals to GP’s or pain management services for review.

The medication trolley was not always stored safely. When not in use, the trolley was left in the lounge. Although the trolley was locked, we observed occasions when the lounge was not staffed, leaving the trolley unsupervised.

We raised these concerns with the provider, who implemented further safety checks for ‘when required’ medications and arranged urgent medication reviews for people who received these medications.