Archived: Rodney House Care Home

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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation.

The provider was also in breach of legal regulations relating to the premises and equipment, staff training and unsafe recruitment.

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.

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. The provider could not demonstrate all accidents and incidents had been recorded, or reported to other agencies, including the CQC when required. In part, this was because the provider did not have access to records which had been completed by the previous management team, who had left the service. Staff were not recording incidents and accidents accurately or consistently. For example, we observed an incident occur when the police attended. When we later asked the management team to provide us with a list of all events which had occurred for the current year, this incident was not included in the records we received. Lessons were not learnt to continually identify and embed good practice. There had been no recent analysis of events which occurred to learn lessons, look at themes and trends or to look at ways to avoid reoccurrences.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Daily meetings to share changes in people’s care with the wider staff team were not consistently held, nor records consistently maintained which meant important information as not always shared effectively.

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 always 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 always share concerns quickly and appropriately. Records were poorly completed, did not always include information about the actions which had been taken by the provider to keep people safe following an allegation, or a concern about abuse occurring. Some incidents had been reported to the local authority safeguarding team however, not all had been reported to the CQC. For example, CQC had not been informed of several altercations which had occurred between people. We identified examples when people had been neglected as they had not received adequate care. We raised a safeguarding alert for one person with the local authority. Staff told us they understood safeguarding procedures and they would report any concerns to the management team however, staff had failed to recognise the need to raise safeguarding alerts for people who were consistently refusing assistance with personal care. Several people were being deprived of their liberty when it was determined they lacked the capacity to consent to their care. This process is known as an authorisation under deprivation of liberty safeguards (DoLS). One person was being deprived unlawfully as their DoLS authorisation had been allowed to expire before a renewal was sought. Another DoLS application contained the wrong name and gender of the person and other applications lacked any detail of why the authorisation to deprive a person of their liberty was being sought.

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. People were not offered appropriate care to meet their personal care needs or needs associated with a particular health condition. Information within risk assessments and care plans lacked detail and failed to guide staff in how to adapt their approach when needed as well as respond appropriately in a medical emergency. Some people had risks associated with the potential for self-harm or attempting suicide. Following an event which had occurred, the provider had not considered purchasing emergency ligature cutters. People’s risk assessments relating to this particular risk were initially not in place and when they were developed were not completed by a person with the necessary skills, knowledge or experience. During our assessment the provider did purchase ligature cutters, however, not all staff knew how to use them, or who they had been purchased for. Some people were at risk of developing pressure care areas. Specialist mattresses prescribed to people to mitigate this risk were unplugged. There were no systems in place for staff to monitor they were switched on and in full working order. Risk assessments and care plans did not direct staff to monitor this for people and to raise any concerns. One person had bedrails fitted to their bed due a risk of falls. The soft covers which had been supplied were not being used which placed the person at risk of entrapment of their limbs.

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.

We observed various holes in ceilings and exposed electrical wiring. Trailing wires were evident in some bedrooms, some floor areas were uneven, and one person’s flooring was heavily damaged and torn. These issues placed people at risk of electrocution as well as injury caused by trips and falls. The home needed a significant scheme of refurbishment. Fixtures and fittings, including bedroom furniture in most bedrooms we viewed was damaged or broken. Some people did not have working blinds on their windows. Multiple windows needed urgent replacement. During the assessment we instructed the provider to undertake a review of the safety of the windows in Rodney House Care Home. We received a report of damage and required repairs, however, no timeframes for completion were provided. People did not adhere to the providers smoking policy and we observed people smoking, and saw evidence of people smoking in communal spaces, bedrooms and bathrooms. Extensive damage had been caused to flooring and furniture from cigarette burns. The provider had put in additional measures to alert staff to smoking around the building however, this was not effective in reducing the risk as other measures to ensure fire safety were not followed. Fire drills had not been completed and routine checks on the fire alarm system had not been completed for a significant period. Environment checks had not identified some fire doors did not close properly and the providers fire strategy stated people with limited mobility would not reside on the upper floors. This was not the case, and staff did not know there was equipment available to safely evacuate people in the event of a fire. Systems were not in place to ensure people’s equipment was maintained. One person had a broken wheelchair. This impacted on their comfort and posture. We raised this with the management team however, no action was taken to seek suitable repairs. Some staff told us they did not have confidence repairs would be undertaken in the service. We were told the hot water urn had been broken for two weeks. One staff member commented, “Nothing gets replaced here.”

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. Staff were not recruited safely. Appropriate checks were not in place to ensure staff were suitable for their role. The provider was using agency staff, however, did not ensure agency staff received an appropriate induction. Staff were not safely deployed across the service, and we observed a lack of staff based on the upper floors of the building. There were insufficient numbers of domestic staff on duty each day. The provider was in the process of implementing an external catering company which would reduce the number of staff needed working in the kitchen. However, one staff told us, “I am not sure how staff will manage as well as the cleaning.” Feedback from people was varied about staffing at the home. Some people spoke negatively and told us staff were “Lazy” and “There are always different faces changing.” However, other people were more complimentary. Comments included, “I am happy here, the staff are nice and helpful” and “Staff are very nice.” Staff lacked the necessary skills, knowledge and training they needed. Training records were poorly maintained. This meant the provider could not demonstrate kitchen staff had completed food safety training, or maintenance staff had received training in health and safety. Members of the management team responsible for responding to and reporting allegations of abuse had not received training in safeguarding. Records were not in place to demonstrate staff were trained to deal with emergency situations such as a fire, administer lifesaving medicines in the event of an opiate overdose, responding to an epileptic seizure or an attempted suicide case by a ligature. This placed people at significant risk of harm.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. One person had a blood borne infectious disease. There was no guidance for staff to follow to mitigate the risk of cross infection. Shared bathroom and toilet facilities were unclean and poorly stocked with toilet roll or paper towels. One person told us, “There is hardly ever any toilet roll.” Most bedrooms, and people’s bedding was visibly dirty. We observed stained bedroom furniture and windowsills, stale and unlabelled food, stained and heavily marked bed bases and mattresses. Most bedrooms were extremely malodourous. Some people did not have bin facilities in their bedrooms to dispose of rubbish and there was limited ventilation due to the poor condition of many of the windows. Some people had ensuite facilities, these needed a deep clean. There was a lack of personal protective equipment (PPE) available for staff to use. Furniture in dining rooms needed to be cleaned and tablecloths were dirty and some full of cigarette burns. Dining areas were not always promptly cleaned after use which meant discarded food and drinks were left lying around. We raised all these issues with the provider and required them to undertake a full review of infection, prevention and control practices within Rodney House Care Home. We received an action plan and were informed the provider had instructed an external company to undertake a deep clean, however, when we returned on a further assessment visit, many of the concerns had not been addressed. There had been an infestation of flies prior to our assessment visit. An external pest control company had been sourced to address this issue, as well as address concerns about reported mice activity in the building. We observed new equipment being fitted to address the flies however, staff had not removed old sticky fly catchers, which were covered in dead flies from people’s bedrooms. One person told us mice were living in their mattress and showed inspectors evidence of this. We raised this immediately so the persons mattress could be replaced.

The provider did not make sure that medicines and treatments were safe and met people’s needs. Staff did not follow safe practices when administering medicines.One staff member was observed carrying multiple people medicines around the communal areas in unlabelled pots within an unsecure box. This meant people were at risk of receiving the wrong person’s medicines. Medicines prescribed to be added to people’s drinks because of a choking risk were not recorded. Prescribed topical creams were not recorded when administered. Risk assessments had not been considered to mitigate the risk to people of smoking once potentially flammable products had been applied to their skin, clothing and bedding. We raised this and a member of the management team put risk assessments in place, however, the risk was not sufficiently mitigated through guidance for staff within people’s care plans. One person had an inhaler which they kept in their bedroom to use as required, however, this had expired. We raised this with the management team however no action was taken to address this.