Applegarth 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 inadequate. At this assessment the rating has remained the same. This meant people were not safe and were at risk of avoidable harm.

​The provider was previously in breach of the legal regulation in relation to safe care and treatment. Sufficient action had not been taken to improve and the provider remains in breach of this regulation. The shortfalls identified also demonstrated a breach of the regulation relating togovernance.

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.

Systems were not effective in ensuring learning from events was identified, implemented and sustained.

Lessons learned were not always identified, documented, reviewed or monitored following complaints, safeguarding concerns, accidents and incidents. As a result, the provider could not fully demonstrate that information arising from these events had been used to reduce risks, improve the quality and safety of care or prevent recurrence. This lack of sustained learning was reflected in staff feedback, with 1 staff member stating, “Applegarth is no longer a learning environment.”

This was the third consecutive inspection/assessment at which the service had not achieved a rating of at least good in the safe key question. Improvements required following previous inspections had not been fully embedded into practice or sustained over time.

An effective system was not fully in place to support continuity of care when staff worked with people and external healthcare professionals to establish and maintain safe systems of care.

Care plans and risk assessments were not always accurate, up to date or reflective of people's individual needs. Staff did not use a structured approach to identify, record and communicate changes in people's health and wellbeing. A professional raised concerns about the quality and structure of communication from staff when reporting changes in people's health and wellbeing. They told us staff did not always provide clear, specific or sufficiently detailed information,

However, we also found examples of systems that supported continuity of care. Face-to-face pre-admission assessments were completed to help determine whether the service could meet people's needs prior to admission. Health and care passport documentation was also in place to support the sharing of important information when people attended hospital or accessed other healthcare services.

An effective safeguarding system was not fully in place.

A professional told us they had raised a safeguarding concern regarding a person's care. We reviewed the provider's safeguarding records and found this concern had not been recorded on the safeguarding log. As a result, there was no documented oversight of the concern, including any investigation undertaken, actions implemented, outcomes achieved or lessons learned.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions attached to authorisations to deprive a person of their liberty had the appropriate legal authority and were being met.

We found that whilst the provider had submitted DoLS applications to the local authority for authorisation, the resulting authorisations had not been notified to CQC as required. The failure to notify CQC reduced external oversight and limited assurance that arrangements restricting people's liberty, and any associated conditions and safeguards, were being appropriately monitored and reviewed.

The provider had already implemented an action plan to strengthen safeguarding processes and improve oversight of safeguarding concerns. In addition, the registered manager told us they would ensure the outcomes of DoLS applications would be notified to CQC in line with regulatory requirements.

An effective system to assess, monitor and manage risks was not in place.

Risk assessments did not always set out clear actions to manage identified risks in areas including behaviour support, nutrition and hydration, moving and handling and supporting people with complex healthcare needs. We identified an instance where moving and handling techniques were used that had not been formally assessed and were not reflected within the person’s care plan or risk assessments to ensure the safety of the person and staff.

Risks relating to people's nutrition, hydration and healthcare needs were not always effectively assessed and managed. We identified inaccuracies and conflicting information within records relating to people who received nutrition, fluids and medicines through a feeding tube directly into their stomach. We also identified that guidance relating to a modified texture diet for 1 person was inconsistent with recommendations provided by the speech and language therapist.

We received mixed feedback about people's safety. Some people expressed concerns about the consistency of the care they received. A person told us, "Safe, well if the good staff are on." However, a relative told us, “I am sure they are safe with (staff). I am very happy that she is there and I wouldn’t want her to go anywhere else.”

The provider had already implemented an action plan to review care documentation, to ensure care plans and risk assessments were in place and improve oversight to ensure records remained accurate, consistent and up to date. This was yet to be fully embedded and shortfalls remained.

An effective system to manage environmental risks was not in place.

Window restrictors did not meet Health and Safety Executive (HSE) guidance which placed people at increased risk of harm from falling. Risks associated with access to balconies had also not been appropriately assessed. In addition, fire safety systems and practices were not sufficiently robust. Records showed the last planned fire drill had taken place in May 2025. Staff told us there had also been no simulations or practical exercises involving evacuation equipment to support them in safely evacuating people. We shared our findings with Cumbria Fire and Rescue Service.

Following our visits to the home, the registered manager told us that appropriate window restrictors had been fitted and immediate steps were being taken to address the fire safety concerns.

An effective system was not in place to ensure staff were suitably skilled and supported.

Concerns relating to staff training and support have been identified across 3 successive assessments including this assessment and this has been reflected in our scoring of this quality statement.

We identified gaps in staff training and development, including areas relating to nutrition and hydration, wound management and record keeping. These gaps in staff knowledge were reflected in staff practice and care records. In addition, staff had not received training in the use of equipment required to support the emergency evacuation of people from the home.

A professional commented on the varying levels of confidence and experience amongst nursing staff. They told us there was limited structure in place to support staff development and felt opportunities to support learning could be strengthened.

Whilst both individual and group supervision sessions had resumed, some staff told us they did not feel fully supported and felt group supervisions were not always effective in meeting their development needs. In addition, planned appraisals had not taken place as scheduled. The registered manager told us appraisals would recommence in September/October 2026.

There were sufficient staff deployed to meet people’s needs. However, we received mixed feedback from people, relatives and staff about staffing levels. A relative told us, “I see plenty of staff, there is always 2 nurses and 3 - 4 carers about." Others felt staffing levels did not always enable timely responses when people needed assistance. A person told us, "They take a while to come if you want them." These findings indicated that, while staffing levels were generally sufficient, people's experiences of staff availability and responsiveness were not always consistent.

No staff had been recruited since our last assessment. The registered manager told us they had amended the interview documentation following feedback provided during the previous assessment, when we identified that interview records lacked sufficient detail.

The provider assessed and managed the risk of infection to help prevent the spread of infection and protect people’s health.

Improvements had been made since our last assessment. The home environment and equipment were clean and we observed staff following appropriate infection prevention and control practices. Staff had access to and used PPE. Relatives spoke positively about the cleanliness of the service. A relative told us, “The place is always clean and tidy."

An effective system was not in place to ensure medicines were managed safely.

We identified continued concerns regarding medicines record keeping, similar to those identified at the previous assessment. Although staff completed regular medicines stock checks and documented potential reasons for discrepancies, this information was not reviewed through management oversight processes to identify trends, contributing factors or opportunities for learning and improvement.

Medicines records were not always complete or accurate. We found instances where it was unclear whether medicines had been administered as prescribed. Records relating to the administration of paracetamol did not always demonstrate that appropriate intervals had been maintained between doses. In addition, records were not maintained when thickening agents were added to drinks. Clear and complete records were not always maintained when fluids were administered via a feeding tube.

We also found that information to support the covert administration of medicines was not consistently available. Records for 2 people did not contain the necessary documentation to demonstrate covert medicines were being administered in accordance with best-interests decisions. Following discussion during the assessment, nursing staff took action to begin addressing this issue.

Despite these concerns, there was evidence of joint working with healthcare professionals to review and manage people's medicines. Appropriate medicines reconciliation checks were undertaken when people were admitted to the home, and person-centred guidance was available to support the safe administration of medicines prescribed on an 'as required' basis.