Ravenstone Care and Rehabilitation 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 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 the legal regulations in relation to safe care and treatment, safeguarding people from abuse or improper treatment, duty of candour and good governance.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

An effective system was not in place to ensure learning from safety events.

Although concerns and shortfalls had been identified through incidents, audits, safeguarding matters, and external feedback, there was limited evidence these were consistently used as opportunities for learning or to drive sustained changes in practice.

An electronic care management system was in place and used by staff to record accidents and incidents; however, the registered manager was not aware of how to download or generate reports from the system to support effective oversight. As a result, accidents and incidents were not analysed to identify trends, themes, or repeated risks, and opportunities to reduce the risk of recurrence were missed. In addition, records did not demonstrate that duty of candour requirements had been met, as there was limited documented evidence of appropriate apologies, follow‑up actions, investigations, or lessons learned following safety incidents.

An effective system was not fully in place to support continuity of care when staff worked with people and external healthcare professionals to establish and maintain safe systems.

Electronic care plans and risk assessments were not always accurate or kept up to date and did not consistently reflect people’s individual needs. As a result, information was not always sufficient to support safe transitions or timely changes in people’s care.

Despite these issues, we received positive feedback from a health and social care professional, who stated that the home participated effectively in clinics and brought appropriate referrals and concerns to their attention. Relatives also told us that people’s needs were assessed prior to people moving into the home through a multidisciplinary approach which involved professionals such as physiotherapists, social workers and staff from the home to help ensure people’s needs could be met.

An effective safeguarding system was not in place. While the local authority had been notified of safeguarding incidents, other agencies, including the police and CQC, had not always been informed as required, which limited external oversight of risks to people. In addition, people’s care plans and risk assessments were not updated following safeguarding incidents. This meant risks were not effectively reviewed or managed, learning from safeguarding incidents was not always used to reduce the risk of recurrence, and people were placed at increased risk of harm due to a lack of effective governance, oversight, and safeguarding arrangements.

Despite these concerns, relatives told us they felt people were safe living at the home. While there was one comment relating to a safety related issue which was being addressed, relatives spoke positively overall about people’s safety. One relative said, “I do think she is safe, it is clean, tidy, warm, and everything she needs.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met.

DoLS applications had been submitted to the local authority for authorisation, in line with legal requirements.

An effective system to assess, monitor, and manage risk was not in place. We identified shortfalls across many areas of the service, including medicines management, the environment, access to equipment, weight loss, and safeguarding; examples of these are detailed throughout this report.

Care plans and risk assessments did not consistently detail the actions being taken to manage identified risks. This included a lack of recorded actions to reduce people’s risk of accessing stairs, supporting people safely in relation to their behaviours and responding to weight loss. As a result, staff did not always have clear guidance to follow, which increased the risk of inconsistent care and meant people were potentially exposed to avoidable harm. These gaps also limited the provider’s ability to monitor whether risks were being effectively managed or whether interventions were appropriate and timely.

Despite these concerns, relatives told us they felt risks were addressed. While there was one comment relating to a safety related issue, which was being actioned, relatives spoke positively overall about people’s safety. They told us people were kept safe and security in the home was well managed.

Following our assessment, the registered manager and nominated individual told us that action was being taken to address these concerns, including the provision of additional training and support on the electronic care management system to ensure records clearly reflected identified risks and effectively guided staff practice.

An effective system was not in place to ensure the environment was safe and that equipment was available to meet people’s needs.

Fire safety checks, drills and training had not been completed as planned and fire doors were not always suitable. There was no maintenance person in post, which had an impact on routine health and safety checks, such as water temperature monitoring.

Equipment to support people’s independence was not always identified or available, including handrails and raised toilet seats. Some people were using divan beds with castors, which were not always suitable for individuals with mobility difficulties or an increased risk of falls. Routine checks to ensure sensor alarms and call bells were working were not carried out, despite a previous incident where a sensor alarm had failed to operate. Staff told us that a hoist or other mechanical aid would be beneficial to safely support people following a fall.

In addition, relatives and staff told us that improvements were needed to the environment. One staff member said, “The home is tired and requires redecoration and new furnishings; the outside areas could be made more service‑user friendly.” A relative said, “It’s a bit tatty but well run, with facilities that are good, clean and tidy.” We also found that window restrictors were integral to the windows, and the registered manager was not able to confirm whether these met Health and Safety Executive (HSE) guidance.

Despite these issues, relatives spoke positively about the homeliness of the environment. One relative said, “I think it is a good home and it is only a small care home and better than a big home, it is like a house and not clinical. There are pictures on the wall and everything. It is calm, quiet and reassuring.”

Following our assessment, the registered manager told us that a maintenance person had been appointed, a hoist had been purchased, they were confirming the compliance of the window restrictors and were taking action to address fire safety concerns.

An effective system was not in place to assess, plan and monitor staff deployment and ensure staff were suitably trained and supported.

Although a staffing tool was in place, this was based on dependency levels and allocated care hours and did not take account of additional duties staff were required to undertake, such as cooking and kitchen responsibilities. We received mixed feedback from relatives about staff deployment. One relative told us, “They probably need more staff, people here have lots of complex needs.” Another relative said there were always enough staff when they visited and they saw the same staff regularly.

An activities coordinator was on duty 2 days per week. When we visited, the activities coordinator was not on duty and care staff were required to work across care provision, activities, and kitchen duties. As a result, staff were frequently moving between roles, which affected the continuity and coordination of care. Essential health and safety checks and tests, including those relating to fire safety, had not been carried out as planned. There was no effective system in place to ensure maintenance related tasks were planned, monitored, or escalated when not completed.

Training had not been carried out as planned. We identified shortfalls in staff practice relating to medicines management, safeguarding, supporting people’s behaviours, compliance with the Mental Capacity Act and record keeping.

Despite these issues, relatives spoke positively about the staff. One relative told us, “I know the staff and the manager. All the carers are lovely and really nice - it’s the same ones and she knows them.”

Recruitment checks were carried out to ensure staff were suitable to work with people. Minor recording issues were identified, which the registered manager told us she would address.

Following our assessment, the registered manager told us that additional training was being provided along with further support to help staff use the electronic care management system effectively. They also informed us that a maintenance person had been appointed, a cook was in the process of being recruited, activities provision had increased to 3 times a week and interviews were being carried out for new care staff.

The infection prevention and control system required strengthening. Wear and tear to fixtures and furnishings compromised the service’s ability to carry out effective cleaning and disinfection. We also identified gaps in the provision of infection prevention and control (IPC) training. The registered manager told us they were in the process of arranging IPC training to address these shortfalls.

Despite these concerns, relatives spoke positively about the cleanliness of the home and all described the home as clean.

An effective system was not fully in place to ensure medicines were managed safely and in line with best practice. Care plans relating to medicines management contained conflicting guidance, since staff were not clear on how to remove outdated information from records. Recording of topical creams and ointments was inconsistent, with gaps identified in documentation. Several topical creams were found to be out of date, these were removed during our visit. Medicines storage arrangements were not in line with best practice guidance to ensure safety and security, since the medicines trolley was secured to the wooden stair banister and an unsecured metal cupboard was located next to the trolley. This increased the risk of unauthorised access to people’s medicines and did not provide sufficient safeguards to keep medicines secure at all times.

Despite these issues, relatives did not raise concerns about medicines management. They told us that medicines were administered safely. One relative said, “It’s safely done. When she was at home she wasn’t taking it and was spilling her tablets on the floor, but here it is all good.”

Following our assessment, the nominated individual and registered manager told us they intended to move to a new local pharmacy. They also told us that steel medicines cabinets and a new medicines trolley had been purchased to improve the safe storage and management of medicines.