78 Hoylake Crescent

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.

The last rating for this key question was good. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

We identified breaches of legal regulations relating to safe care and treatment, premises and equipment and staffing.

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 always promote a learning culture for staff to develop proactive strategies for managing incidents. People living at the service had mental health needs. Sometimes people expressed their frustration, anxiety or anger in ways that challenged the staff. Staff told us they responded to these incidents by reporting the incidents to managers to deal with. They told us they were not involved in discussions to help them learn and develop proactive strategies. The recorded response to most incidents was staff telling people to calm down or that their behaviour was not acceptable. For example, 1 record stated, “Staff told [person] [their] behaviour was not good.” There was no analysis of why incidents occurred or proactive strategies to help prevent these. In another record, there had been an incident which escalated because a person had tried to help the staff with a task. The record stated they were told not to do this. There was no plan to enable them to help with tasks and be involved in the future.

Records of incident debriefs did not include a review the planned care or identify triggers for incidents. Additionally, staff told us these debriefs were created by managers alone and were not discussed to help learn together.

Failure of the provider to involve staff, and people using the service, in learning from incidents to develop future care meant people were not supported to understand and manage the risks to their safety.

The provider supported people to have safe transitions between services. Managers liaised with external professionals to share information about people’s needs. This helped ensure others involved in their care knew these needs and how to communicate with them.

The provider had imposed restrictions on some people without properly assessing these or ensuring they were agreed as lawful and the least restrictive option. Staff locked 1 person’s en-suite shower room and only allowed the person supervised access to this. This restriction was not part of their care plan, had not been assessed and had not been discussed with external professionals. We discussed this with the management team. They explained the restriction had been imposed because of an identified risk. They acknowledged this had not been assessed or agreed as part of the planned care with the person or external professionals. They agreed to review the practice.

During our assessment, 2 people described incidents where they felt unsafe, including 1 person telling us staff had shouted at them. We discussed these incidents with the management team. They agreed to investigate these and raise a safeguarding alert with the local authority if needed.

The provider had procedures to help safeguard people from the risk of abuse. Staff undertook training in these. Staff were able to explain what they would do to recognise and report abuse.

The provider did not always manage risks to people’s safety and wellbeing. Cleaning products were not always stored securely. This meant there was an increased risk of these being misused.

Managers had assessed risks associated with people’s care and wellbeing. They did not always share information from these risk assessments with staff. This meant staff did not always understand or know how to mitigate these risks.

The environment was not safely maintained. The London Fire Brigade visited the service in September 2025 and issued an enforcement notice relating to fire safety risks. The provider had not taken enough action to mitigate these risks at the time of our assessment. Some internal doors did not provide sufficient protection against fire, and some did not close properly. Staff were not familiar with the fire evacuation plan. The provider had not implemented extra steps to ensure safety whilst the repairs to fire doors were being undertaken.

The hot water from outlets in some bathrooms and bedrooms exceeded safe temperatures and presented a risk of scalding.

A window restricting device in 1 bedroom was broken and devices on other windows were not robust enough. This meant people could open the windows wide enough to climb or fall out of these.

There were areas of the building which required repair. These included a broken radiator cover which meant the hot surface of a radiator could be exposed and a damaged mattress on someone’s bed.

There were no locks on the downstairs toilet or upstairs bathroom doors.

A person told us the design of the shower in their en-suite room meant that the floor became wet when they had a shower and this made them feel unsteady and worried about falling.

The provider did not always ensure suitable staff were deployed to meet people’s needs and keep them safe. Records showed that some staff regularly worked continuous shifts exceeding 24 hours and in some cases 36 hours. For 12 of these hours the staff were lone working. This meant there was an increased risk people would receive unsafe and unsuitable care from staff who were tired and could not work effectively.

The provider carried out checks on potential staff prior to employment. We saw evidence of this. However, for 1 staff member the checks had not been robust enough. The provider had not verified references or followed up missing information. This meant there was an increased risk the staff member may not be suitable. We discussed this with the management team who agreed to review the information and assess any risks if they could not obtain all the information they needed.

People were not always protected from the risks of the spread of infection. Areas of the environment and equipment were dirty. For example, a shower mat which was covered in black mould and mops used to clean the floor left in buckets of dirty water.

Staff did not follow some of the systems to help prevent and control infection. For example, we witnessed incidents when staff wore disposable gloves to complete different tasks and wore the same gloves moving around the building. There were no paper hand towels in bathrooms or toilets.

The provider had developed schedules for cleaning. Areas of the building looked clean. However, our findings indicated deep cleaning, and a review of some systems was needed to reduce the risks associated with the spread of infections.

People did not always receive their medicines safely or as prescribed. During the day of our visit to the service, a person attended a hospital appointment. They were prescribed an essential medicine which they required during the time they were away from the home. Staff did not take the medicine with them and therefore this was not administered when the person needed it.

We discussed this with managers. There was no system for taking this medicine, or a different emergency medicine for another person, out of the service. Staff and managers told us this did not happen. There was an increased risk to the health and wellbeing of both people because there was no process to ensure their medicines were available if needed when they were away from the home.

Medicines were not always stored correctly or safely. Upon arrival at the service, we found 1 medicine cabinet was unlocked with the door open. Medicines stored within this were not secure. Other medicines were stored on top of a different medicines’ cabinet. These rooms were not secured and were accessible to people living at the service, staff and visitors. A person’s emergency allergy medicine was stored in the controlled drugs cabinet. This meant staff had to take extra steps to access this which could delay treatment.

Staff did not always follow medicines procedures. Staff did not sign medicines records until over an hour after they had administered 2 people’s medicines on the day of our visit. There was a gap on the medicine’s records for 1 person for a previous day which meant it was unclear whether they had been administered this. Failure to correctly record medicines administration increases the risk of errors.

The provider had not taken enough action to mitigate risks when 1 person regularly had their morning medicines several hours later than the prescribed time. This meant the gap between doses was not in line with their prescription. Staff did not record the exact time of administration, and the variation in time had not been checked with the prescriber to ensure there was no adverse effect.

Failure to manage medicines in a safe way meant there was an increased risk to people’s safety and wellbeing.