The Red House Welfare & Housing Society

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 people’s 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 listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We found that some accidents and incidents had been recorded in individual care plans. However, there was no evidence that these were investigated to determine the cause. The registered manger confirmed there was no analysis of accidents and incidents to identify themes and trends. Lack of analysis meant that there was no learning from this type of event which could be shared and used to prevent re-occurrence.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

There were no clear systems in place for people transitioning between services. People did not receive continuity of care in a person-centred way as care records contained inconsistencies and did not accurately reflect the person’s level of need. This meant information could not be easily provided to other professionals or hospital should the person be admitted.

The provider did not have a robust and safe system in place to ensure that people’s care records contained sufficient guidance for staff to follow. We found there was a lack of clear, timely and consistent information about people’s health needs where they may be receiving care from different services.

Where people were receiving support from external professionals, for example district nurses there was no system to record feedback and ensure guidance was followed by the staff.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. 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.

The provider did not identify concerns quickly and appropriately. As already stated accidents and incidents were not investigated to enable the root cause to be identified and addressed. Risks associated with people’s care and treatment were not always recognised. Safety issues relating to medicines administration, environmental safety and governance were found during the assessment. These had not been recognised and addressed by the registered manager or provider. Although the majority of staff had completed safeguarding training, we were given examples of incidents which may have been safeguarding concerns which had not been reported by staff. This lack of action directly undermined the practical effectiveness of the training provided.

Following feedback from staff given directly to the provider, the provider had not recognised the potential of a closed and bullying culture within the service. No action had been taken following staff raising concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The registered manager told us that 2 people living in the service had a DoLS authorised by the local authority. However, they told us there was no system to monitor these to ensure these were regularly reviewed to ensure they remained relevant to the person.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people were not always identified, understood or documented to allow staff to provide care that consistently ensured people’s safety. This included risks posed by the home environment, medications and health conditions. Where incidents had happened, people’s care plans had not always been updated with appropriate guidance of how to prevent the event from reoccurring. A member of care staff told us there was limited information sharing regarding any accidents or incidents.

Where people had been identified as at risk of dehydration and needing their fluid intake monitored this was not carried out effectively. Care plans did not contain details of the amount of fluid a person should consume and recording was inconsistent. Where a very low intake had been recorded for a person, no action had been taken to address this. One person who had a particularly low intake had developed a urinary tract infection which can be caused by a lack of enough fluids.

Other risks such as constipation and weight loss were not monitored effectively. A safeguarding investigation regarding a person’s bowel management was substantiated and concluded the person had experienced harm because of neglectful care/acts of omission by the service.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider had failed to ensure the environment was safe.

We found issues relating to the environment that placed people at risk of harm. Hot water pipes in bathrooms were not covered which presented a risk of burns should people fall against them. Staircases within the service were not protected which meant that people at risk of falls could freely access them. The service risk assessment for accessing stairs referred to stairs being protected by safety gates but this had not been implemented. During our inspection visit we witnessed a person who used a walking aid using the stairs. They appeared very unsteady and at risk of falling.

We found a toilet with a towel rolled up under the U bend. We spoke with staff and maintenance who were unable to explain why it was there. Some carpets in the communal areas were worn and did not lie flat presenting a trip hazard. There was hazard or duct tape on some stair treads and doorways where the flooring was worn and presented a trip hazard. However, whilst the registered manager told us they were unaware of the hazard tape or any actions around it, there was a risk assessment around this issue which they had signed in April 2025. The registered manager told us that environmental concerns were addressed as they arose but there was no overall maintenance plan.

We observed items subject toControl of Substances Hazardous to Health (COSHH) regulations in an unlocked cupboard during our first inspection visit. This was brought to the attention of a senior member of staff who told us they would address the concerns. However, during our second visit we found the item was still in the unlocked cupboard which risked them being accessed inappropriately.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

The registered manager told us they used a dependency assessment tool to assess the required staffing level to meet people’s needs. However, they also told us that although the care needs of people living in the service had increased this had not been reflected in increased staff on shift.

Staff told us staff numbers regularly went below the assessed level. Describing the impact of this on care a member of staff said, “It means we rush care; we can only give hair a quick brush not styled. We have no time to do make-up.” Another member of staff told us being short staffed meant that they did not get time to talk with people which meant care provision became task orientated.

Some people living in the service preferred care from female staff. However, on several occasions only male night staff had been on duty at night.

Although the training records showed a good level of staff training completion there was no system of spot checks or supervision to ensure staff were implementing their training and were competent. A member staff also told us that the training they received was not sufficient for them to perform their role and they had sourced external training privately.

Staff raised concerns about the effectiveness and consistency of the disciplinary process. Some staff felt that report of inappropriate workplace behaviour, including allegations of bullying and verbal abuse, were not always investigated or addressed satisfactorily. Concerns were also expressed that certain behaviours were not appropriately challenged and that accountability was lacking, resulting in issues remaining unresolved.

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.

We asked the registered manager for a copy of the service infection control policy, but this was not provided. Infection control was on a list of service audits, but nobody had been allocated to carry out the audit.

We observed unclean bathrooms. In one bathroom a metal bar was chipped and rusty, some paintwork in the service was chipped with the bare wood exposed. In a different communal toilet we saw that a towel had been placed under the U bend. These concerns prevented surfaces from being effectively cleaned.

Environmental cleanliness issues and lack of oversight increased the risk of infection and did not ensure people were protected.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

There was limited oversight of medicines processes at a service level, and we did not see evidence of regular audits or routine checks of medicines records. The provider could not demonstrate a well-embedded approach to learning from medicines incidents, which reduced assurance that risks and errors were consistently identified and addressed.

We identified concerns in several areas of medicines practice. Controlled drugs (CDs) were not always managed in line with the service’s policy, as routine balance checks were not consistently completed. Temperature monitoring for medicines storage was not robust, and records showed some areas had exceeded recommended ranges without clear action taken. Confidential information relating to medicines was not always disposed of securely. All of these shortfalls pose a risk to people receiving their medication as prescribed.

Care planning and risk assessment did not consistently reflect medicines-related risks. This included limited risk assessment for higher-risk medicines, such as methotrexate (a cytotoxic medicine that can pose a risk to those handling it), and a lack of fire risk assessments for people using paraffin-based skin products. Emollient residue can increase the risk of burns and there are cases where these have been significant or even fatal. Records for some medicines, including transdermal patches, were incomplete and did not fully reflect safe administration and disposal practices. Failure to manage risk and record properly puts people at risk of avoidable harm.

Processes for “as required” (PRN) medicines and covert administration (where a medicine is hidden in food or drink) were not consistently safe. PRN protocols were not always available at the point of administration, and electronic MAR records did not consistently include key information, such as reasons for use and maximum doses. Records relating to covert administration did not demonstrate decision-making in line with the Mental Capacity Act, including the absence of clear best interest decisions, capacity assessments and pharmacy advice for giving medicines covertly.

Medicines were not always stored securely. During our inspection visit we observed medicines kept in their bed room by person who self-administered were stored in their room in unlocked cabinets. Without proper risk assessments in place this could be a risk for them or others who enter room.