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 assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

At our last inspection undertaken in Autumn 2025, we found people were exposed to the risk of harm because risks to their health and safety had not been adequately assessed, and not everything reasonably practicable had been done to mitigate these risks. At this inspection, we found improvements had been made. For example, accidents and incidents were routinely logged, reviewed, and reported under local procedures. We found evidence of effective root cause analysis and lessons learned. For example, debriefs with staff looking on how to improve on lessons moving forward, evidence of family involvement and sharing information during ‘resident of the month’ and information had been shared with the local authority. However, following the recent departure of the deputy manager, we found there was some inconsistency in the review process. This meant opportunities to identify themes, patterns, and trends could be missed. The interim manager had already identified this shortfall and was addressing it.

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.

Staff liaised with the GP regarding any changes in people’s needs or identified risks. For example, we saw staff had contacted the GP over dietary concerns for a person. This resulted in a referral being made to the Speech and Language Therapy (SALT) team. When people’s mobility declines staff contacted the GP to request for a referral to be made to the community physiotherapist team for an assessment. Staff also worked with specialist services such as the dementia and mental health teams.

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.

We found where people were subject to restrictions which may constitute a deprivation of liberty, such as the use of sensor mats, CCTV monitoring, and locked doors, appropriate decision-specific mental capacity assessments and best interest decision-making records were in place. However, there was no evidence of Mental Capacity Act 2005 assessments or best interest decisions relating to internal bedroom moves, with only records of discussions available. In addition, one person's DoLS authorisation (a legal permission given by a local authority or court to restrict a person) included binding legal conditions requiring mental capacity assessments for medication and personal care, but there was no evidence to demonstrate these had been completed.

People told us they felt safe. One person said, “I like it here. I’m safe I don’t hurt myself.” Another person told us, “I love it here. I’m safe.” A relative said, “[Person’s name] is safe here. They are safe from any injuries.”

Staff received training in how to identify and alert others to potential abuse involving people who lived at the home. The provider had safeguarding procedures in place to ensure the relevant external agencies, such as the local authority and the Care Quality Commission (CQC) were notified of any suspected or witnessed abuse. Safeguarding incidents were being investigated appropriately.

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.

At our last inspection undertaken in Autumn 2025, we found a lack of guidance for staff in people’s care plans on how to reduce known risks. At this inspection, we found improvements had been made, and care plans detailed individual risks such as pressure sores, choking, and falls. However, we identified a few care plans still lacked specific details. For example, one person's plan did not note the correct air mattress pressure, so maintain safe pressure levels. For another person, the care plan stated they were independently mobile, but care notes showed staff were repositioning them every 2 hours. A third care plan lacked detailed guidance on catheter care, such as when to empty the bag and related infection control steps. We raised these issues with the manager, who updated and rectified the care plans immediately.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Since our last inspection all the people, apart from one person, living at Breach House had moved downstairs. One person who had capacity had chosen to remain upstairs. At this inspection we saw improvements had been made to the home environment. Windows were fitted with restrictors and tamperproof screws, there were no exposed hot water pipes and wardrobes and other furniture over 1metre were securely fixed to the wall. We did not see any accessible items across the service in communal areas and vacant rooms which could cause harm to people if ingested.

The provider had an up-to-date fire risk assessment where there were 4 actions identified as needing completing. Three of these had been completed and one was outstanding in relation to 2 fire doors and frames. These had been ordered. All staff had received updated fire safety training and there was a fire marshal on each shift. Fire drills were being carried out however, records lacked sufficient detail to effectively evaluate their effectiveness. For example, documentation did not include the duration of evacuations, whether drills were planned or unannounced, or the evacuation strategy used. In addition, people living at the service had not been involved in fire drills. We shared this with the manager and nominated individual, who assured us they would update documents to include this extra detail and would ensure people living at the service were involved with fire drills when appropriate.

Personal emergency evacuation plans (PEEPs) were in place and had been reviewed. However, records were not always accurate. For example, one person's PEEP, reviewed on 9 July 2026, stated they required an evacuation sledge despite living on the ground floor and not being bed-bound. In addition, PEEP audit summaries for June and July 2026 recorded 10 residents, while 11 people were using the service. As a result, the provider could not be assured PEEPs were consistently accurate and reflective of people's needs.

At the last inspection, the provider’s business continuity plan had incorrect information, which made it unreliable in an emergency. At this inspection, the plan still had mistakes and lacked key details. For example, it did not include backup plans for staff shortages, medicine management, and power loss. It also wrongly said the nominated person would handle evacuations, even though they did not work at the service all the time. After our onsite visits, the provider sent proof they updated the plan with the correct details.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Although the registered manager and deputy manager had left their roles there was an interim manager in post. The interim manager had been a Care Quality Commission (CQC) registered manager at Breach House in the past. Since our last inspection a head chef and activities coordinator had been appointed. There were enough staff for the people they were supporting. In cases, when staff levels dropped, For example, after 2pm other staff from other departments were utilised to be present when staff were assisting people such as to the bathroom.

Regular team meetings had taken place. These could be further strengthened to include more key areas for discussion, which was discussed with the manager. Staff had regular supervisions, and staff appraisals were booked and planned for August 2026.

All staff spoken with spoke highly and fondly of the people they supported and confirmed there were currently enough staff. Rotas were accurate and reflected staff on shift each day. Staff had completed relevant training to enable them to carry out their roles effectively and safely. This included training in areas such as dementia awareness, manual handling and basic life support training. All people we spoke with told us they felt staff were well trained. Staff told us they were supported by senior members of staff, the manager and the provider.

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.

The home was clean. One person said, “My room is always clean. The cleaner comes in and cleans it thoroughly. They take everything off the windowsill and wipe it down. They are very good.”

At our last inspection we found there was issues with hot running water in different areas of the home. There were still some issues with hot running water at this inspection in 3 communal downstairs toilets and in 1 staff area. This was in hand and being addressed. We were provided with evidence these issues had been resolved post our onsite inspection visits.

Records showed and staff confirmed they had received training in infection, prevention and control (IPC). The provider had an up-to-date legionella risk assessment in place. The home had a food hygiene inspection and was rated 5 star by the local authority’s environmental health team. This meant food hygiene standards were very good and fully comply with the law.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and as prescribed. One person said, “The staff do my medication and stay with me while I take it.” Another person who had been diagnosed as having diabetes told us, “Staff do my medication for me. I have one tablet in the morning and one in the evening. Sometimes the staff stay with me they know me as a person who has capacity, so they sometimes leave the cup and I take it myself.”

PRN ‘as and when’ medicine protocols were in place. However, where people were prescribed medication for constipation the normal stool type was not recorded within the PRN protocol but was recorded in care plans. The manager updated the PRN protocols to include this during our inspection.

Control drugs, (CD), which are subject to higher levels of legislation for monitoring were recorded accurately and clearly. Where people had their medicines covertly (receiving medication in a disguised way such as hidden in food or drink) appropriate supporting documentation was in place.

Staff had received medication training and had their competency assessed to ensure they were administering medicines safely. This included competency assessments on applying creams. We discussed with the manager how these competency assessments could be further strengthened. For example, including discussion points and scenarios to ensure staff full understanding, knowledge and competency is captured.