Breach 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 inspection we rated this key question requires improvement. At this inspection 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 regulations in relation to safe care and treatment, safety of the environment, the management of incidents and risks to people’s health.

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. They did not listen to concerns about safety and did not investigate or report safety events in full. Lessons were not learnt to continually identify and embed good practice. The provider had not been effective in identifying areas of improvement within the home environment to reduce the risk of people injuring themselves.

People were exposed to the risk of harm because risks to their health and safety had not been adequately assessed, and not all that was reasonably practicable had been done to mitigate such risks.

Staff completed accidents records, mainly where people had experienced falls. However, the incidents were not always reviewed adequately by the manager, nor logged and reported under local procedures.

Incidents, accidents and falls were not being thoroughly analysed for themes and trends to prevent a recurrence. The system for reviewing incidents and accidents was not being used effectively and therefore the manager and provider were unable to demonstrate how they had learned from incidents or mitigated on-going risk. For example, where a person had climbed out of a window and injured themselves, a full review of the incident had not taken place to ensure risks were mitigated for the person, and potentially others. There was also no evidence that detailed debriefs were taking place with staff to understand and learn from incidents. Where people were at risk of falling, sensor alert mats were generally provided, however other alternative strategies and technologies had not always been considered.

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.

People’s care records were not always comprehensive and up to date, especially where their needs may have changed. This meant staff and healthcare partners may not have access to robust information and guidance about people’s care and health needs. For example, 1 person had transferred from another home and then had a number of stays in hospital after moving to the home, yet their care records had not been updated despite changes to their health. This meant staff could not always support people effectively as care records were not accurate.

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. At previous inspections we found safeguarding incidents were not investigated appropriately or reported to the local authority and CQC. We found on this inspection this had continued and had not improved. A safeguarding policy and procedure was in place, however the provider did not ensure the manager always followed this.

People were being deprived of their liberty without appropriate authorisation to do so. We found sensor mats were utilised without clear explanation. There were no decision specific capacity assessments in relation to this or evidence of any best interest meetings to determine what least restriction options had been considered. There was no evidence these decisions had been re-visited to ensure they remained the least restrictive options in line with the MCA. This meant that those restrictions were being imposed on people without the appropriate authority to do so.

People we spoke with told us they felt safe with the staff who provided their care; however, some people told us they didn’t know who the manager was. One person told us, “I have no idea who the manager is, but I’d speak to 1 of the staff who are of use if I needed to”. Another person said, “In the main I’m okay and feel safe, mainly because there are people around me”.

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

There was a lack of guidance for staff in people’s care plans on how to reduce known risks, meaning there was a risk of people developing skin conditions or pressure ulcers. Other risks such as people’s risk of falling or risk of choking were not properly assessed and actions not put in place to mitigate these risks. There was limited evidence available to confirm care planning decisions had been discussed with people and their representatives. People told us, “No chats about likes and dislikes or how I like things done”, and “In a morning when they [staff] come in, they wake me up saying ‘come on lazy bones’, they made a joke of it”.

People were not involved in their care planning. People we spoke with told us “I'm not asked to plan my care” and “I’ve not been asked anything as far as I’m aware”.

People were at risk of harm from the lack of risk assessments, staff’s limited understanding of risks and the failures in robust quality monitoring by the manager and provider.

Following the inspection, we took urgent action to ensure the provider acted promptly to rectify immediate concerns.

The provider did not always detect and control potential risks in the care environment. The safety of the premises was not robustly checked or managed to support people to stay safe. Whilst the manager undertook monthly health and safety audits, these had not identified all the concerns found. Since the previous inspection there has not been sufficient improvement around the management of environmental risks.

We continued to find windows were not always fitted with restrictors and where they were, the restrictors used did not always meet the Health Safety Executive (HSE) guidance, which has been in place since 2012.

Despite monthly recorded checks, the manager and provider had failed to identify areas of exposed hot water pipes which posed a risk of scalding to people. The monthly checks had also failed to identify the risk of furniture over 1 metre high posing a risk of injury to people who had impaired mobility.

We found accessible items across the service, in communal areas and vacant rooms, which could cause harm to people if ingested. This included gloves, aprons, toiletries and razors. This placed people at risk of serious harm, which could be fatal.

Despite some people living at the service being assessed as high risk of falls, we found the manager and provider had not completed an environment risk assessment in relation to accessible stairways. For example, all stairways were accessible to people who could fall and seriously injure themselves, however no assessment of the staircases had been completed to consider the on-going risk of people falling.

The provider did not have an up-to-date risk assessment in relation to the management of fire safety risks and had failed to identify risks posed to service users in the event of a fire breaking out. This placed service users at significant risk of harm. The last fire risk assessment the provider had on file was completed by an external company in November 2023. This risk assessment identified the need for work to have been completed by February 2024, and included updated training for staff, appointing a fire marshal on each shift, making sure fire drills were being completed, updating the fire alarm system and ensuring all breaches in walls and compartments were adequately fire stopped. We found the manager and provider had failed to complete this work. As a result of our concerns, we made a referral to the fire service and requested they visit the premises to ensure fire safety controls that were currently in place were safe.

Personal emergency evacuation plans (PEEPS) were in place for people, however, they were not sufficiently detailed and, in some cases, inaccurate, so we requested they were updated promptly. PEEPs collate all the essential information staff and emergency services need to know about each person living at the home. Most staff had not completed fire training, and fire drills hadn’t been taking place, despite the provider having a policy that indicated drills should have been undertaken six monthly at a minimum. This meant not all staff had refreshed their learning to deal with emergencies such as a fire.

The provider’s emergency contingency plan and evacuation plan provided guidance to staff on how to manage an evacuation. However, the documents were not up to date and contained contact details for the previous manager, who no longer works at Breach House, and the contact details for 2 out of the 4 organisations recorded as temporary places of safety were incorrect. This meant the provider’s emergency contingency plan and evacuation plan were not reliable.

The design of the service did not align with best practice and legislation. There were gaps in knowledge among the management team and provider in relation to providing care to people living with dementia. Nationally recognised evidence-based guidance, from organisations such as Skills for Care or Age UK, were not used when designing and delivering care to them. The building decoration and layout did not support best practice, people’s well-being or independence. This demonstrated a lack of knowledge and a failure to research and access best practice guidance regarding dementia friendly environments which could have led to improvements in people’s well-being and independence.

Following the inspection, we took urgent action to ensure the provider acted promptly to rectify immediate concerns.

There were insufficient numbers of suitably qualified, competent, skilled and experienced staff deployed within the home. This placed service users at risk of harm and of receiving unsafe or delayed care and support.

We received mixed feedback from people and visitors about staffing. Whilst staff had worked with people for many years and spoke of them fondly, we found some staff provided task centred care. One person told us, “I get myself up out of bed, but they tell me I need a shower and when I can have it. I would prefer a morning shower, but I have to wait for staff to be available”. Another person said, “9pm and they [staff] turn everything off and say ‘bedtime’, we can be watching TV but it’s still turned off, and we are ushered to bed”. A third person told us, “Most [staff] are kind, some are nasty because I’m vocal”. A fourth person said, “The new deputy is good, we’ve been doing more since they came and staff seem happier”.

The manager showed us the tool they used to help them calculate a safe staffing level for the home. This document was not fully complete and appeared to be based on out-of-date information. Further adding to staff response times, was the layout of the building which meant staff had multiple areas to cover, and this had not been considered when determining staffing levels. There had been a number of falls in the service, and we were concerned that if someone rang their call bell or activated a sensor mat to alert staff they were attempting to walk, the limited number of staff on shift may not be able to react quickly enough to protect them from further harm.

Rotas we reviewed for August, September and October 2025 were not accurate and did not reflect staff on shift each day. We found evidence that showed less staff were working on each shift than the provider had told CQC and the local authority. The provider did not make sure staff received effective support and development. Staff had not completed all training relevant to their role, to ensure they could meet people's care and treatment needs. For example, not all staff had been provided with training on safe moving and handling, and dysphagia (swallowing problems). This placed people at risk of harm.

Staff were not supported with regular supervision, meetings and appraisals, and these had not always been carried out in line with the provider’s policy. The manager told us they were addressing this. Most staff told us they felt supported by the management team and were able to seek guidance where required. However, others told us they were concerned the manager wasn’t always available and any concerns they had raised with the manager and the provider’s representative hadn’t been addressed. Staff told us having more staff on shift would allow them to spend quality time with people instead of having to rush around.

Overall, systems were in place to ensure staff were recruited safely. However, we found some gaps in records relating to recruitment requirements. For example, we reviewed 3 staff recruitment files and found there were missing references and DBS checks had not been completed in a timely manner. DBS checks provide information including details about convictions and cautions held on the Police National Computer and helps employers make safer recruitment decisions. This meant the provider could not be assured of the staff’s suitability to work at the service.

Following the inspection, we took urgent action to ensure the provider acted promptly to rectify immediate concerns.

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 received multiple reports from staff the washing machine had broken down twice, and it being repaired or replaced took time. In the interim, staff told us they were taking people’s washing home to wash to ensure people had clean clothing, bedding and towels. The provider’s representative told us they had arranged for a local laundry company to provide a laundry service in the interim, whilst the machine was being repaired.

Not all staff had received training on infection prevent and control (IPC). The manager completed a monthly IPC audit; however, we found this was not accurate. For example, the audit completed indicated alcohol gel was available at the point of need and was in plentiful supply. The manager informed the inspection team alcohol gel was available in all PPE stations and, “dotted around the building”. Inspectors checked PPE stations on all 4 days of site visits and could not locate any alcohol hand gel. A gel dispenser fixed to the wall was found to be empty on all 4 days of site visits.

We found most areas of the home were clean however, we noted there were towels, flannels, and toiletries in shared bathrooms which posed a risk of cross infection. One person’s bedroom had a strong smell of urine that remained throughout the 4 days we were on site at the home, which staff also acknowledged. However, no action had been taken to address this prior to our visits.

We found issues with hot running water in different areas of the home across all 4 days of our visits. The provider’s representative and the manager told us they weren’t aware of any issues with a lack of running hot water and suggested the taps needed to be run for a longer period to pull the hot water through from the boiler. A person told us, “Occasionally, there’s no hot water, if I get up early the water usually cold”. On 8 October 2025, the inspection team checked 22 bedrooms and found 10 had lukewarm water running from the hot tap. On 27 October 2025, our inspection team checked 16 occupied bedrooms and found 1 bedroom continued to not have any running water from their sink hot water tap. Plumbers were onsite so the manager reported they would ask them to resolve the issue.

Our inspection highlighted the provider had not ensured the home had an up-to-date legionella assessment and check in place. This placed people at risk of contracting legionella from a water system that hadn’t been routinely maintained as per the provider’s own policies and procedures.

Following the inspection, we took urgent action to ensure the provider acted promptly to rectify immediate concerns.

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

Overall, systems were in place to ensure people received their medicines as prescribed. Staff provided good information about why people might need PRN (as and when required) medicines. However, we found some gaps in records and areas where staff needed to follow procedures more robustly. For example, where people were prescribed medicines ‘as required,’ protocols were in place to guide staff about when to administer these. However, care plans did not include information for people’s needs around creams or PRN medicines. Where people had limited capacity around medicines and the need for PRN or covert medicines, there was no supporting documentation in place to enable the service to make the decision on their behalf.

We found records for administration of creams had gaps. However, these were stored in the medicines room, which restricted access for staff as they needed a key to enter this room. The deputy manager arranged for the records to be moved to people’s rooms so staff could sign the records off immediately after creams had been applied to ensure records were more accurate.

We found limited evidence of regular medicine competency checks in place to ensure staff were competent to administer medicines safely. Additionally, not all staff had received medicines administration and medicines awareness training.

People told us they were happy with how their medicines were being managed. One person said, “They [staff] bring medication to me, I’m diabetic, I’ve been told what they are but forget, I just take them”. Another person said, “Staff deal with medication no problems, no painkillers I don’t need them”.