Redcourt

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 staff training at the service.

This service scored 56 (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 have a proactive and positive culture of safety based on openness and honesty. Recording of accidents and incidents was inconsistent. For example, some were recorded on accident forms, some were written as a support record in people’s care files, and some were recorded on antecedent-behaviour-consequence (ABC) charts. We found these had not always been reviewed by the registered manager. Additionally, there was no overall review or analysis of accidents and incidents by leaders to spot themes and trends, or areas for improvement. This meant we could not be assured lessons were always learnt to continually identify and embed good practice.

However, the provider received support from an accredited external provider to review learning following individual incidents where people communicated signs of distress. Staff took immediate action to keep people safe following accidents or incidents, such as seeking healthcare advice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People were supported to transition into the service smoothly. Staff and leaders took time to get to know people as they moved into the service. Relatives reflected on their experiences positively when discussing their loved one’s transition into the service, acknowledging the efforts by staff to ensure families were involved.

Guidance was in place to aid transitions into hospital, such as a hospital passport. This meant key information about people’s care and support could be shared quickly as needed.

When concerns about abuse were raised, action was taken to keep people safe. Staff demonstrated a good knowledge of how to be alert for signs of abuse, and how to report these, including how to escalate above the provider. A professional who worked with the service described them as responsive. Safeguarding records reviewed showed the service worked in partnership with relevant agencies to ensure safeguarding concerns were addressed when raised.

People and relatives told us they felt safe using the service. A relative shared, “No concerns about safety, I can go in and talk to them about stuff, they are very open and act on anything.”

Improvements were required to the overall reviews of accidents and incidents. As themes and trends were not analysed, we could not be assured effective systems to recognise recurring risk, and take preventative action, were in place to keep people fully protected from the risk of potential abuse.

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

As people were supported by a consistent staff team, staff knew people and the management of risk well. We observed staff supporting people and their known risks safely. However, we found some care plans and risk assessments did not always fully reflect staff knowledge in supporting people safely. For example, specific details on how a person may communicate signs of distress. Furthermore, some care plans contained out of date information, duplicated or inconsistent information, which had not been removed. This placed people at risk of receiving the incorrect support. The registered manager took immediate action and updated these care plans.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People were cared for in a safe and accessible environment. The premises, equipment and facilities were all maintained to a safe standard. Where people required specialist equipment to keep safe, such as adapted wheelchairs, these were observed to be readily available and in good working condition.

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. For example, staff had not received regular supervisions.

Not all staff were up to date with mandatory training. Gaps were identified in training such as learning disabilities, fire awareness and medicine administration. Furthermore, we were not fully assured staff had received sufficient or appropriate training to support people with a learning disability and autistic people for their role in the specialist service type. The provider explained staff had completed training titled, ‘What is a learning disability’ during induction, but training records showed for some staff this was up to 8 years ago. The training also included misinformation, inappropriate terminology, and was not underpinned by current evidence-based practice. This did not support the principles of ‘Right support, right care, right culture’ which requires people with a learning disability and autistic people to receive care that is tailored to their needs, promotes their quality of life and is delivered in a culture that respects their rights, dignity and individuality. The lack of sufficient or appropriate training placed people at risk of receiving unsafe or inappropriate care.

The provider did not have effective oversight of staff training. The registered manager assured us action would be taken to ensure training was completed; however, this was only after it was raised by the inspection team.

There were enough staff to meet people’s needs. People were supported by consistent staff teams who knew them well. The provider followed safe recruitment practices.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The premises and equipment were observed to be clean. Spillages were observed to be cleaned quickly. People were supported to maintain their personal hygiene. Staff followed best practice guidance in relation to donning and doffing personal protective equipment.

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

Oversight of medicines was not robust. Medicine audits did not effectively address areas for improvement. For example, a sample of medicine audits showed gaps in medicine administration records (MAR) had been identified. No action plans were created to address these shortfalls. During our assessment we found some gaps in MAR which were not rectified until raised by the inspection team. We were assured people had received their medicines, and this was a recording error.

Protocols for, ‘as required’ (PRN) medicines did not always contain sufficient information to ensure these medicines were administered appropriately. For example, if someone could not verbalise they were experiencing pain and may require pain relief. Whilst staff could describe how people would communicate pain or distress, this was not always reflected in records. The registered manager agreed to update these protocols to reflect the information required. We found no evidence to suggest these medicines had been administered inappropriately.

Medicines were stored safely and securely.