Florence 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 good. At this assessment 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 regulation in relation to safe care and treatment.

This service scored 25 (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 based on openness and honesty. They did not identify concerns about safety and did not investigate or report all safety events. Lessons were not learnt to continually identify and embed good practice.

Audits, including those for care plans, weights, nutrition and environmental walk rounds by the manager, were not taking place. This limited the provider’s ability to identify patterns, learn from incidents and embed improvement in care.

We identified the provider had failed to record all incidents or report these to CQC as required by law. This omission meant opportunities to review incidents, take action or learn lessons to make improvements to people’s care, and protect them from future risk, had been missed. This had placed people at risk of harm.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. Care and support were not always planned and organised with people or their relatives, as they were not involved in care plan writing or reviews. They did not always manage or monitor people’s safety. For example, people’s weights for 2025 had been lost. They did not always make sure there was continuity of care. For example, appointments and meetings with health care professionals were not consistently being recorded, which risked people receiving inappropriate or unsafe care and on ensuring information was shared between services.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve it. 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. The provider did not share concerns quickly and appropriately.

There was no system in place to monitor incidents to ensure safeguarding referrals were made, investigated as required and notifications made to CQC. There was no identification and recording of outcomes from referrals, any actions taken or lessons learnt.

There was a safeguarding of vulnerable adults’ policy in place. The policy did not refer to making notifications to CQC or that staff could approach CQC or the Local Authority Safeguarding team directly. Staff received online training, but when we spoke to staff, although they understood safeguarding, they were not all aware they could report straight to CQC or the safeguarding team.

The provider did not always work well with people to understand and manage risks. Risk assessments were not always accurate and did not contain up-to-date information which reflected the current care and support needs of people who lived in the service. For example, for one person, the provider had failed to identify the need to assess, mitigate and review risks relating to falls and distressed behaviour and this had placed the person at risk of harm.

Positive behaviour support plans were poor or non-existent and assessment tools to understand and analyse people’s behaviour had not been completed when it had been identified they were needed for a person. When they had been completed there was no review to identify themes and review care and support plans to ensure they meet their needs.

Staff told us they did not feel they had enough training to meet people’s needs in relation to de-escalation and self-harm, which put people at risk of not receiving appropriate support when they needed it most.

The provider did not always detect and control potential risks in the care environment. We identified multiple risk factors in relation to the environment and the provider’s lack of oversight and processes meant these had not been identified or mitigated and this placed people, and staff, at risk of harm. For example, the provider had failed to risk assess the completion of building works within the care environment and this meant people had access to items they could use to self-harm. Furthermore, we found risks relating to the use of asbestos within the care home and the provider had failed to ensure staff had received regular fire drills, further placing people at risk of harm.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not consistently received the training they required to support people and their specific needs, particularly in relation to autistic people and people living with a learning disability. Staff told us the training they did receive was not wholly effective and/or did not provide them with the confidence they needed to provide dedicated care. In addition, we identified concerns with staffing levels and skill mix. From reviewing the staff rotas, we identified 12 shifts out of 21 where staffing levels were less than what the provider had assessed the service as requiring to meet people’s needs and keep them safe. The people who used the service, and their relatives, also raised concerns there were not consistently enough staff on shift to meet people’s assessed needs. We also saw shifts where untrained or inexperienced staff worked together and, where the service used agency staff, the provider had failed to seek assurances that those staff were suitably trained to work with the people who used the service.

The provider did not assess or manage the risk of infection. They did not always ensure issues were identified in a timely manner. There had been an infection prevention and control (IPC) audit completed in May 2025, but it failed to identify the issues found at this inspection.

For example, we found rusty and/or damaged fixtures and fittings meaning effective cleaning would not be possible. Furthermore, there was no system in place to manage dirty and clean laundry and staff told us they did not always have the products and/or personal protective equipment (PPE) needed for their roles. Whilst we found cleaning schedules in place, they did not provide staff with full information on what areas needed to be cleaned and how often.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. They had not identified concerns with medication administration and taken appropriate action to ensure people were not put at risk of harm.

We identified examples of where people had not received their medicines as prescribed. Out of the 7 people whose medicines we assessed, we found errors with 4 of them. These had not been identified by the provider, and no action had been taken to investigate the potential omissions. These included conflicting records in relation to the management of one person’s diabetes. In addition, we found staff did not consistently have enough accurate information to administer and manage people’s medicines prescribed on an ‘as required’ basis. Furthermore, the providers procedures in relation to people who self-medicated had not been followed and we found concerns in the management of topical medicines. We raised these concerns with the provider who took some action to address the omissions.