Dauntsey 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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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. Incidents and near misses were recorded and reviewed by the registered manager to ensure actions were implemented. Learning from incidents was shared with all staff to ensure they understood changes in the way they needed to support people. Examples included changes in equipment used for people at high risk of falls and availability of information for staff to provide assurance to a person and prevent distress.

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 and relatives told us systems worked well when they first moved to the home, with good communication. People’s health conditions were documented, and they were supported to access services from a range of professionals. The provider ensured information was shared appropriately with other professionals, including sharing assessment documents with other services where appropriate. Health professionals told us the service worked well with them to meet people’s needs, with comments including, “We have a good working relationship with the management team and the staff, who participate regularly with our organisation in areas such as medicine management and ward rounds.”

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.

Relatives said they felt people were safe living at Dauntsey House. Staff demonstrated a good understanding of their safeguarding responsibilities and said they had completed safeguarding training and had regular discussions about safeguarding issues. Staff were confident the registered manager would take appropriate action if they reported any safeguarding concerns. Staff were aware how to raise any safeguarding concerns outside of the provider organisation if they needed to. Where appropriate the provider had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. The registered manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At the last inspection risks relating to people’s distressed reactions were not being effectively managed and action to prevent a recurrence of incidents was not taken. At this inspection we found the provider had made improvements.

People and relatives told us they felt safe. Risks to people’s health, safety and welfare had been assessed and plans developed to manage those risks. People now had emotional support plans where needed, setting out details of how to support people during periods of distress. Staff demonstrated a good understanding of the risks people faced and how to support them safely. Staff told us risk management plans were regularly reviewed and updated as people’s needs changed. Staff had access to updated plans through the electronic care planning system and were notified of any changes. Comments from staff included, “I feel risks are well managed in the home” and “We have extra staff to help with managing risks for [person].”

The provider did not always detect and control potential risks in the care environment to support the delivery of safe care.

The provider had worked with the fire authority to address previous shortfalls in fire safety arrangements in the service. Most actions had been completed, although an action to complete fire drills in nighttime conditions had not. Night staff had completed fire drill training, although this had been done during the daytime, when conditions and staffing levels were different. The registered manager told us they would take action to ensure night staff completed further drills to simulate nighttime conditions.

Equipment, including the lift, boiler, water systems and hoists had been regularly serviced and tested to ensure they were safe. Staff told us action was taken quickly when repairs were needed. The registered manager told us they completed extra training when legionella was detected in the water system. Remedial works were completed by an external contractor, including replacement of a water tank. Subsequent samples had been sent for analysis, and no legionella was detected.

The provider did not always make sure staff received training in a timely way or that anomalies in recruitment checks were followed up.

The provider had completed required recruitment checks when staff started work in the service. However, we identified some of the records contained conflicting information, which was not followed up by the registered manager. Examples included dates on references received for staff which did not match the dates staff had given on their application form and employment histories which did not contain full information about the dates the staff worked with an employer.

Training records identified gaps in training for some staff, including practical training in moving and handling, communication training and nationally recognised training in autism awareness. The registered manager was aware of the shortfalls, which had been caused by their previous training contractor leaving. Plans were in place to catch up with the missing training, with courses scheduled during November and December 2025.

People and relatives felt there were enough staff available with the right knowledge and skills, and said staff responded quickly when they requested assistance. Comments included, “There always appear to be enough staff, and the staff are always on the floor, which means they can see and hear if anyone needs them” and “I feel that they know [relative] and understand their needs.”

Staff told us they felt there were enough of them to provide safe care and said they received regular support and supervision.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People and relatives told us the service was always kept clean. We observed staff following good infection prevention and control practice, to help keep people safe. Staff said they had completed infection prevention and control training and had access to all the equipment they needed.

People were supported to take the medicines they were prescribed. However, the provider did not always make sure information about the support they needed was clearly recorded.

At the last inspection we identified medicines were not being managed safely.The provider had addressed most of the shortfalls and was no longer in breach of legal regulations.

The provider had introduced a new electronic recording system since the last inspection. MAR now contained full information about people, and the route medicines should be administered. Staff now completed body maps when they supported people to apply topical cream medicines and recorded where topical medicine patches had been applied. At this inspection no-one was being supported to take their medicines covertly. The provider now had systems to follow if people needed covert medicines, including checking with a pharmacist that the medicine was safe to be mixed with food or drink. The provider now had protocols for people who were prescribed medicines to be taken ‘as required’. However, the protocols did not always contain information about how people communicated the need for this medicine, for example, people who could not verbally tell staff. This registered manager took immediate action to amend these protocols during the inspection.

People told us they were happy with the support they received with their medicines and were able to get additional pain relief when needed.