Working at Breach House

The service lacked a positive safety culture and failed to respond properly to concerns. Safety incidents were not consistently investigated, recorded, or used to improve practice.

Staff morale was mixed, with some reporting that concerns, including alleged medication errors, were ignored or not investigated fully.

There were insufficient numbers of suitably qualified, competent, skilled and experienced staff deployed within the home. This placed service users at risk of harm and of receiving unsafe or delayed care and support.

Staff had not completed all training relevant to their role, to ensure they could meet people's care and treatment needs. For example, not all staff had been provided with training on safe moving and handling, and dysphagia.

Leadership was ineffective. Managers lacked visibility, oversight and the skills required to ensure safe, person-centred care.

At the time of the inspection there was no activity co-ordinator in place, and staff took it in turns to provide activities for people.