The White House

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• 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. This is the first assessment for this provider at this location which they took over from the previous provider in July 2024. This key question has been rated 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 people’s safe care and treatment, people being protected from the risk of abuse, the environment and equipment not being maintained to a safe standard, staff not being deployed or trained effectively. The infection, prevention controls were not robust, and the home smelled strongly of urine. The maintenance of the service and the equipment people were using was poor. There were many falls at night and the provider had not considered the deployment of staff in relation to this. People were concerned about other people entering the rooms at night. The provider had not taken steps to address this. People were being admitted to the service in quick succession before the provider had fully undertaken a review of their needs.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Accidents and incidents did not have detailed information recorded on the actions taken to reduce further occurrence. For example, according to an incident report a person had gone into another person's room and hit them. There was no information on how either person had been supported. There were no clear documented actions as to what had been done to prevent this from occurring again. On another occasion a person sustained a skin tear however there was no detail on what actions had been taken to reduce further risks of this. The majority of the incidents and accidents had not been signed off by a member of the leadership team to confirm they had been reviewed and appropriate action taken.

People's distressed behaviours were not always formally recorded on an ABC chart therefore allowing a robust analysis of any triggers. [An ABC chart is a direct observation tool that can be used to collect information about the events that are occurring within a person's environment.] Staff were required to record when people displayed a distressed behaviour within their daily care notes and on the ABC charts however this was not always taking place. This meant preventative measures were not always being taken to reduce further distressed behaviours.

assess their needs, including distressed behaviours. Between August 2024 and January 2025, 15 people had been admitted; 5 of these being in January 2025. Of these, there were people that were known to have distressed behaviours prior to them moving in. There was little opportunity for their distressed behaviours to be analysed before other people were admitted. This meant there was a potential that any new person being admitted might trigger behaviours in people already living at the service. Staff told us it was difficult to ensure people’s care was appropriate when so many new people had been admitted in quick succession. We also found the documentation used to assess people’s needs before they moved was not detailed and at times the provider was relying on the assessments undertaken by the funding authorities. This meant they could not be assured of all the needs of the person before they moved in.

However, when people did move, staff did all they could to make the transition for them as comfortable as possible. One senior member of day staff told us they stayed in 1 person’s bedroom for a few nights to help reassure the person as they were initially unsettled when they moved in.

The provider had failed to understand their responsibility to report all safeguarding concerns to the local authority safeguarding team. There were safeguarding incidents that had not been notified to the local authority as required. These both included physical assaults from one person to another and an allegation made against a member of staff. This was despite the safeguarding policy being clear on when incidents needed to be reported. Although staff received safeguarding training, when asked staff did not always know who they needed to contact outside of the service if they suspected abuse. Comments from staff included, “I would go to CQC”, “I am a carer, I know how to handle abuse. I just understand the situation, it's about them choosing the better option” and “I would go to [manager] or the provider.” One member of staff told us they did not know the local authority had a safeguarding team. This meant that there may be a delay in safeguarding concerns being reported to the appropriate organisation should the leadership team not be available to report this. People and staff that told us that people felt safe with staff with comments including, “I feel safe. I don’t feel like I’m going to get hurt” and “I get the sense he feels safe, I think [person] would say.” However, people also raised concerns that other people would walk into their room, particularly at night. One person said, “That happens all the time, another day a lady went to come into my room, what I have to do is press my buzzer, it happens at night too and sometimes it scares me.” Whilst we were speaking to a person in their room a person did walk in and was gently encouraged by the person to leave. There were no staff around on the floor to ensure this did not happen. A member of staff told us, “[Person] goes into other people’s rooms all the time. The carers are always in the lounge. There is no carer based upstairs. Some people stay upstairs and there should be someone based up there.”

The provider did not work well with people to understand and manage risks. Risk assessments relating to the health, safety and welfare of people using the service were not always completed. This meant guidance was not always in place for staff to ensure they supported people in a safe way. For example, where people were at risk of falls, risk assessments were not always in place to mitigate further risks to the person and to maintain their safety. The risks associated with people's behaviours and the strategies to manage this were not always clear in people's care plans. After the visit, the manager had made us aware of concerns raised in January 2025 by a member of staff observing another member of staff not always using moving and handling when supporting people to reposition. However, there were other risk assessments that were completed and updated when a change occurred for example in relation to nutrition and hydration and skin integrity. Staff, in the main, were familiar with the risks associated with people’s care. Staff ensured people had their walking aids left with them.

The provider did not always detect and control potential risks in the care environment. They did not make sure that the environment and equipment supported the delivery of safe care. We observed multiple people were sleeping on mattresses that were on top of mattresses, often the top mattress being longer than the base of the bed. The bottom mattress may not support both mattresses adequately, causing uneven weight distribution and potential discomfort to people. There was a risk people would slip off the bed. There were headboards in people’s rooms just resting against the bed risking injury to people. In several bathrooms including in people’s rooms, there was no hot water coming from the taps and at times the taps were hanging loose. In the upstairs bathroom there was an unlocked cupboard with a boiler with exposed pipes. The radiator covers in two rooms were not fixed and came away from the wall when you pulled on them. This placed service users at risk of falling if they were to lean on them to steady themselves. There was a radiator that did not work in 1 bedroom and a toilet that didn’t flush in another room. Despite these being reported as broken by people, no action had been taken to address this. A relative told us, “New owners started taking over, it’s not in the best decorative state. The rooms need modernising. [Person] has a massive telly, and it’s just propped on the side and it’s a hazard.”

There was adequate number and selection of moving and handling equipment to assist staff to support the people requiring transfer that had been regularly serviced. Equipment was available to assist in the evacuation of people. Fire exits were clearly marked and free from obstruction and fire evacuation plans were displayed throughout.

The provider did not make sure there were enough qualified, skilled and experienced staff deployed effectively around the service. The manager and staff told us 3 staff worked at night to support 29 people. In addition, we saw from staff meeting minutes in February 2025, that night staff were also required to clean parts of the service, ironing and sorting people’s washing. We noted from the incident reports there had been 19 falls with people during the night shift. Yet the provider had not considered whether this pattern indicated a need to review the current staff deployment of staff at night. This lack of action placed people at further risk of harm. Whilst we observed there were sufficient numbers of staff in the day, they were often congregated in the lounge areas whilst there were people in other parts of the service, including upstairs, that chose to stay in their rooms. One person told us, “The staff hardly come up here, they all stay downstairs.” A relative told us, “Im always surprised how many [staff] there are in the lounge. They tend to congregate there.”

The provider did not always make sure staff received effective training, supervision and development. We noted from training records that staff completed 16 e-learning topics in one go on the same day. This was not an effective way to ensure that staff learned and understood the appropriate care that needed to be provided to people. When we spoke to staff at the service, the majority lacked understanding of safeguarding procedures, the principles of the Mental Capacity Act and dementia.

The provider operated effective and safe recruitment practices when employing new staff. This included requesting and receiving references and checks with the disclosure and barring service (DBS). DBS checks are carried out to confirm whether prospective new staff had a criminal record or were barred from working with people.

The provider did not assess or manage the risk of infection. When we arrived at the home on 4 March 2025 there was a strong smell of urine throughout all of the communal areas including on the carpets, chairs and pressure cushions. In some people’s bedrooms, the carpets smelled strongly of urine as did their mattresses and bedroom chairs. Staff told us the smell of urine had been at the service since before the new provider took over. The provider told us they were aware of this however they had not taken appropriate action to address this. We found there was a large urine stain one 1 mattress. Staff told us this had been left to dry without appropriate cleaning taking place. Urine can lead to unpleasant odours, bacteria, and potential mould growth if not properly cleaned. This placed people at significant risk. Staff told us that some people struggled with their continence and would at times refuse personal care. At times people sat on the lounge chairs with wet clothes. The chairs were not cleaned immediately afterwards which meant other people were sitting on them whilst they were still wet. One member of staff said they regularly changed people’s bedding but felt there were not enough urine neutralisers to help get rid of the smell. A relative told us, “I have not noticed any difference with the smell, I think pads aren’t being changed as much as they should.” The provider failed to ensure people were protected from the risk of infections as appropriate cleaning was not taking place. The state of repair of the environment, and items contained within it, is also important in ensuring that germs and bacteria do not persist. In particular, surfaces that are not smooth and intact can harbour bacteria. Other areas around the service were not clean and posed a possible infection control risk. We found the woodwork was worn, the carpets in all areas were worn. The touch points on doors, door frames and handles around the home were dirty.

Whilst there were people that received their medicine as prescribed, there were elements to the management of medicines that were unsafe. Multiple medicine administration records (MAR) had no photograph of the person. This risked staff administering the medicine to the wrong person. Where people had handwritten MAR for example, for ‘as and when’ medicines, there was only 1 staff signature instead of 2. Having a second member of staff observing and signing lessens the risk of inaccurate information being written on the MAR.

However, we found MARs contained information about allergies and how people preferred to take their medicines. There were body maps for topical creams in place to ensure staff knew where to apply the cream. Where people required medicine patches, staff were recording where they last applied the patch to reduce the risk of applying in the same place and to reduce the risk of skin irritation. Liquid medicines had opening dates written on the bottles to ensure they were still within date and safe to apply.