Archived: 23 Perryn 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.

The service was in breach of legal regulation in relation to safe care and treatment, safe and effective staffing, safeguarding people from abuse and improper treatment, good governance, and Duty of Candour.

This service scored 47 (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 demonstrate a proactive or positive culture of safety. Staff did not always work in accordance with the provider’s polices relating to reporting incidents. This reduced the provider’s ability to monitor events, respond in a timely way and identify patterns that could help prevent future harm.

The provider had recognised gaps in incident reporting through its own safeguarding review and had included actions to address this in its service improvement plan (SIP) dated 16 January 2026. However, these actions were still being implemented at the time of our inspection.

We reviewed an incident where a person suffered life changing injuries due to a fall. A review of the person’s care records showed staff had not worked in accordance with the Duty of Candour. This sets out specific requirements that providers must follow when things go wrong with care and treatment. This includes informing people and their relatives about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. Care records showed the person affected and their representatives had not received the required open and honest explanation, apology or updates about what had happened. This limited transparency and missed an opportunity for learning.

Staff meeting minutes from 19 December 2025 showed managers had reminded staff to record all incidents and safeguarding concerns accurately. During this inspection we found examples of repeated poor practice which indicated that learning was not yet embedded across the staff team.

While the improvement plan recognised some issues, failures to identify and mitigate health related risks, had not been included. We fed this back to the management team who were receptive to our feedback. The updated SIP reflected what we had found with dates where identified actions had to be completed.

The provider had a ‘Referrals, Moving People in and Out’ policy, which outlined the steps managers were required to take when a referral was received. This included completing an initial assessment and presenting information to the provider’s Risk Enablement Panel with relevant internal specialists and external health and social care professionals involved. We could not determine whether these processes were being followed in practice or whether they supported a safe and robust admission pathway because relevant documents such as initial assessments were not made available to us during or after or assessment.

Referrals to health and social care professionals were not always made promptly when people’s health changed. For example, we noted several people were above a healthy weight, which affected their diagnosed medical conditions, yet there were no records showing staff had sought appropriate external support. We fed this back to the management team. Following our assessment, the provider shared evidence confirming that the necessary referrals had since been made.

People were not always protected from the risk of abuse or avoidable harm because management were not always aware of any allegation or evidence of such abuse. We found staff did not always report incidents in accordance with the provider’s reporting incidents policy which meant safeguarding concerns were sometimes missed.

There were also concerns about the safe management of people’s finances. Prior to our inspection, we received anonymous whistleblowing information which highlighted potential financial mismanagement relating to 2 people. We found the former registered manager was not aware of their responsibilities to prevent, identify and report financial abuse because these concerns were not picked up on their audit of finances.

The provider carried out an internal investigation, which confirmed what the whistleblower had shared. The provider’s action plan showed steps had been taken to ensure people’s money was safeguarded and handled by senior managers only.

People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). The authorisation procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). We found authorised DoLS were in place for people using the service.

Prior to our inspection the provider had identified, amongst other issues, the under reporting of safeguarding incidents as a concern and had raised a safeguarding alert with the LA.

The provider did not always work with people or their relatives to understand risks or support them to manage these safely.

Relatives told us they were not always involved in reviews of risks. A relative described reporting ongoing bruising and rashes without seeing any changes to risk assessments or how the person was supported. Another relative reported raising concerns about repeated falls; although some adjustments were made to mitigate this risk, this was not reflected on the person’s risk assessment and care records showed relatives were not always involved when risks to people’s welfare and safety were reviewed.

The service did not consistently provide a safe environment. We found repeated environmental and fire safety issues, including unsecured cleaning products, accessible kitchen knives, an overflowing skip and a wedged-open fire door. The area manager later confirmed a safe had been purchased for knife storage and provided evidence the skip had been removed.

The provider’s Falls Risk Prevention Toolkit required a falls checklist and a Falls Risk Management Plan for anyone at increased risk, but these were missing for 2 people assessed as high risk. This meant staff lacked essential guidance to support them safely.

Incident records showed 1 person had several falls over three months, yet this was not reflected in their care plan. As a result, staff did not have an accurate understanding of the person’s risks, and measures to prevent further harm were insufficient.

Staff did not always identify or assess risks linked to people’s health needs. Although care plans described peoples diagnosed conditions and the support required, risks associated with these conditions were not always assessed, and actions needed to prevent deterioration were not consistently identified.

The provider’s service improvement plan identified these concerns before the inspection, and management had begun reviewing all completed risk assessments. However, these improvements were still in progress and had not yet resulted in consistently safe practice.

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.

Fire safety systems were not always implemented; no fire drills had been completed in the past 12 months; the provider’s action plan identified staff had not read or signed Personal Emergency Evacuation Plans (PEEP). This meant, people could not be assured staff would always be able to evacuate them safely in the event of a fire.

These concerns were also identified on the provider’s and local authority’s joint improvement plan. We noted actions were in progress to address them.

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.

The service did not always operate with safe staffing levels, which affected people’s care and wellbeing. The provider’s staffing assessment identified 4 staff as sufficient for 6 people, but it did not take account of the 5 people who required additional 1-1 support. There was no structured system showing staff allocation or records of support hours worked. During our visits, we observed occasions where people did not receive the individual support they required, this has been reported under the Caring section of this report.

The service had not planned staffing around peak care needs, increasing the likelihood of unmet care needs. Staff rotas were unclear, lacking named staff responsible for 1-1 support and missing start and end times for enhanced observations. These issues had been identified in two audits conducted by the local authority in December 2025 but had not been actioned by the provider at the time of our visit.

Some staff did not receive regular supervision or appraisals, and others had not completed thorough inductions or probation periods. As a result, staff were not consistently supported to develop the skills and confidence needed to carry out their roles safely and effectively.

We observed and found that a new agency worker was inducted without being given any information about the individuals they were supporting, which the area manager confirmed should have been provided. The area manager quickly took action to ensure the agency staff was given the relevant information.

A family member told us about being left alone with people in a communal area for over an hour due to lack of staff presence, this feedback was shared with the provider.

Following the inspection, rotas were reviewed and showed sufficient staffing numbers and 1-1 support was provided.

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.

The service was not always consistent in its infection prevention and control (IPC) practices and arrangements, and systems were not sufficiently embedded to ensure consistent protection from infection risks. Staff had access to personal protection equipment (PPE) and hand hygiene resources, but the provider did not have cleaning schedules or documentation demonstrating routine cleaning, meaning monitoring and oversight were not assured.

Environmental shortfalls were observed, including missing waste disposal facilities, odours in communal areas, and the laundry room being used as a sluice, which increased cross contamination risk.

The provider’s monthly audit identified many of the same issues during the inspection, showing responsiveness but it also confirmed concerns were not being proactively identified through regular IPC governance processes.

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

The provider did not consistently ensure medicines were managed safely or in a way that met people’s needs, capacities or preferences. Important instructions were missing from essential documentation for example, 1 person’s hospital passport and medication profile stated their tablets must be crushed, yet their medicines administration records (MAR) contained no printed “crush” instruction or prescriber authorisation. This created both safety and legal risks. Systems for monitoring and recording medicines were unreliable, with incomplete MARs, missing staff signatures, no topical medication administration records (TMARs) in use, and no record of people’s preferred methods of taking their medicines. These issues meant staff could not demonstrate medicines were administered consistently or in line with individuals’ needs.

Storage arrangements were also unsafe and required improvement. The medicines cupboard was visibly untidy, overcrowded and contained undated creams and liquids, meaning staff could not confirm these were safe to use. There was no medicines fridge, and 1 person’s medicated creams were stored in a domestic refrigerator alongside food and drink, despite this having been identified in a previous audit. Stock control was poorly managed, with large quantities of unused and unreturned medicines accumulating and returns stored with active stock. These issues significantly increased the risk of medicine errors. A medicines fridge was purchased following our visit, and some concerns were addressed promptly following feedback.

There was limited evidence of appropriate oversight of psychotropic medicines in line with STOMP principles. STOMP is a national NHS England program to Stop the Over-Medication of People with a learning disability, autism, or both, with psychotropic medicines. A few people were prescribed antipsychotic medicines, but the service did not demonstrate review, reduction planning, as required (PRN) protocols, or consideration of non‑medicines approaches. One relative told us their GP recommended reducing antipsychotics, but the provider had argued for an increase. A review of the person’s care record confirmed what the relative had said. Additionally, not all staff had completed the required competency assessments, leaving only a small number authorised to administer medicines safely. These concerns were also reflected in the provider’s and local authority’s joint improvement plan, with actions underway but not yet embedded.