Stratford Road

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 good. At this assessment the rating has changed to 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.

This service scored 56 (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. The managers told us it was not possible to have staff meetings because it was difficult to release staff from their support duties to be able to attend. This was an issue the provider had identified themselves in their most recent quality audit but had not found a solution. This meant staff could not come together to discuss the people they supported and talk about progress as well as aspects of practice where lessons could be learnt and improved upon. The provider had also identified how the lack of team meetings had meant staff had not been able to discuss aspects of medicine management with one another as a way of supporting their learning.

The provider did not always maintain safe systems of care, in which safety was managed and

monitored. Systems for recording medicine administration were not always completed and the processes in place were not robust enough to identify this. People had hospital passports in place which meant staff unfamiliar with them would understand their needs should they be admitted into hospital. However, some important information such as allergies were missing in 1 person’s hospital passport.

The people living in the service were settled and had lived there for a number of years and were supported to seek healthcare professionals when they needed them.

The provider used their care planning system as a tool to assess and review people’s needs to ensure all areas of a person’s life was addressed.

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 were not always able to demonstrate processes for identifying whether restrictions were needed. For example, we saw restrictions were in the process of being reviewed for 1 person which were not needed.

The person we spoke with told us they knew who to talk to should they have any concerns. They said, “I can talk to any of the staff, and I know I can talk to those two [Manager and Deputy Manager]; I talk to them a lot.”

Staff were confident about reporting concerns and what they needed to report. A staff member told us how they would complete an incident form and alert the manager.

The manager told us they were confident staff would raise concerns if they needed to. They told us how they had worked with staff to ensure they felt at ease reporting concerns and how they felt such transparency helped to protect people.

The family member felt there was an openness with the service and told us they could air anything that concerned them about any aspect of their family member’s care.

The provider did not always work well with people to understand and manage risks. At the time of the inspection we found there were externally fitted bars over upstairs windows preventing them being used as a means of escape in the event of a fire. This was highlighted as a concern in a fire risk assessment carried out in July 2025. The provider had failed to identify and act upon this concern.

Whilst these restrictions were highlighted in deprivation of liberty safeguard documents, there was no corresponding risk assessment stating why such actions were necessary. We were told by the manager, measures in place around restricting the opening of windows were not intended for the person and had been put in place to meet general security requirements for the building prior to the person living there.

1 person had risk assessments in place to help manage a particular need which had health and safety implications. Whilst there was a formal diagnosis in place and the risk was reviewed; staff were not always consistent as to how much this posed a risk to the person.

People had risk assessments in place for other areas of their care and support. For example, there were assessments in place for people going missing in the community which informed staff about measures to take to help avoid this and what to do if it occurred.

Staff we spoke with were confident in how to manage a situation where new risks emerged. They told us how they would make sure the person was safe in the first instance before talking to their managers to ensure the risk was documented.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities were safe. There were hazards to people’s safety such as broken equipment and items unnecessarily stored that created risks which audits failed to identify. Systems to identify environmental risks were not carried out effectively. Fire safety checks were carried out, however, we saw an electric heater in use despite being in need of repair.

A person’s settee was torn and was in a state of disrepair. We talked to the staff member on duty who acknowledged these issues and told us a programme of redecoration and refurbishment was planned. They also informed us people were responsible for buying their own furniture and this is done with the involvement of families.

The provider made sure there were enough qualified, skilled and experienced staff, who received regular supervision. The manager told us they had difficulties getting staff together for team meetings owing to people needing constant support which meant freeing staff up was difficult which meant important information was difficult to discuss and share as a staff team. The manager told us the staff team was stable and where necessary they used bank staff who were familiar with the people they supported when required. The provider had robust recruitment procedures in place. This meant staff were recruited in line with current legislation which included for example, references from previous employers and criminal records checks.

The managers told us how they involved people in recruitment. They told us 1 person is involved in asking questions and prospective staff got to meet the people as part of their interview process. Staff received training on how to support autistic people and people with learning disabilities to enable them to understand the needs of people they supported.

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 were supported to be involved in cleaning their flats as much as possible. A person told us, “I clean my own room and tidy it up myself. Staff do a lot of other cleaning, and they are here to help me do a lot of it.”

The flats were clean and staff were provided with personal protective equipment and appropriate cleaning materials to ensure environments were clean and the risk of the spread of infection was kept to a minimum.

The provider did not always make sure that medicines and treatments were safe. People’s medicines records were not always accurately completed. For example, we found 1 person’s medicines chart had not been signed for by staff and it was not clear whether medicines had been administered. A medicines audit carried out 3 days after, failed to identify and address this discrepancy.

Medicines were not always stored safely. We found medicines stored unlocked in a kitchen cupboard. Risk assessments for the storage of medicines in the kitchen had not been completed and monitoring temperatures had not been completed for these medicines.