Redcote House Residential 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 requirements improvement. At this assessment the rating has remained 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 people’s safe care and treatment.

This service scored 50 (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 report safety events. Lessons were not learnt to continually identify and embed good practice. Staff did not consistently record incidents which meant patterns and trends were not analysed to reduce the risk of reoccurrence. Debriefs were not completed with staff to discuss what had been done well or what could have been improved to manage the risk more effectively. There was missed opportunity to identify areas for improvement to increase people’s safety and minimise the need for restrictive interventions like the risk of overusing medicines for people in distress.

The provider did not always make sure care plans and other records were up to date to ensure a continuity of care, including when people moved between services. People’s care plans were not consistently up to date with the most relevant information. Risk assessments were not always carried out when necessary to show identified risk and how it was managed. This meant if a person needed to go to hospital or transfer to another service, they were at risk of not being safely supported in line with their needs and preferences.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. There was a lack of transparency, open communication, and external scrutiny, which increased the risk of harm and abuse. The provider did not share concerns quickly and appropriately. We found incidents where people had hit or on one occasion bitten another person which had not been referred to the local safeguarding team or notified to CQC.

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. Care plans did not give clear guidance on how to support people in line with their assessed needs which meant they were at risk of inconsistent and unsafe support. For example, information for people with diabetes had not been appropriately incorporated into their care plans to ensure staff knew how to support them safely.

The provider had not carried out risk assessments where risk had been identified. For example, a person who was taking large amounts of sedative medicines was at significant risk of falls due to their sedative effects, which could cause drowsiness, impaired balance, and slowed reaction times. We could not be assured staff were supporting people appropriately when they were distressed because records were not always completed when medicine used to treat distress were administered. Most relatives told us staff were kind to their relative, however, another relative told us they thought training probably didn’t cover the complexities of their family member’s situation.

Environmental checks and maintenance were completed. We saw regular checks had been carried out to ensure the home was safe, however actions identified by external professionals had not always been completed in a timely manner to ensure the building was safe. For example, serious breaches had been identified in a fire risk assessment carried out in November 2024. Actions had not been taken to ensure compliance with fire safety even though it stated on the risk assessment that serious concerns should be rectified as soon as possible. Personal emergency evacuation plans (PEEPS) contained basic information and did not give staff enough information about where to find equipment to support people who could not evacuate independently. There were no signs around the building showing staff where equipment to evacuate people was located. In an emergency, staff may have been unable to locate the equipment to safely evacuate people which put them and staff at risk.

The provider made sure there were enough qualified, skilled and experienced staff, who received support and supervision. Most relatives we spoke with thought there were enough staff to support their family member. However, the recruitment process was not robust enough to ensure positions were offered to suitable applicants. We checked 3 staff files which all had gaps in their employment history with no explanations. Any unexplained gaps or discrepancies in employment or training history should be explored during the interview process and appropriately risk assessed when this information cannot be obtained. Although training relevant to their role had been completed by most staff, we found inductions for new starters were not always completed which meant we could not be assured new staff had been prepared to provide safe, compassionate and high-quality care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies. However, the service needed some maintenance to ensure areas could be effectively cleaned to prevent the spread of harmful bacteria. For example, there were unpainted surfaces that could not be wiped cleaned and perished sealant around some basins which could harbour bacteria. Most relatives told us they thought the service was clean. A person told us, “The place is always clean, it could do with a lick of paint.” Staff understood their responsibility to use appropriate personal protective equipment (PPE).

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were used regularly for people experiencing distress without appropriate records to ensure they were being used proportionately and as the last resort. This meant there were inconsistent records that could support investigation, analysis and implementation of preventative measures to improve people’s quality of life. Important information was not always included in care plans and risks were not always assessed when people were taking certain types of medicines. For example, a person was taking medicines that put them at higher risk of excessive sedation. Information had not been incorporated into their care plan and risks had not been assessed to ensure staff knew how to support that person safely.

Diabetes care plans used by district nurses had not been incorporated into peoples’ care plans to ensure staff had access to relevant information such as potential signs of hypoglycaemia or if blood sugar levels were too high and what actions to take. For diabetes that was tablet controlled, care plans contained limited information and guidance about how a combination of diet and oral medication was to care plans are crucial to ensure people with diabetes receive proper management, preventing complications and improving their overall well-being.

Medicine Administration Records (MAR) were not always clear to ensure safe medicine management. For example, some medicines had been handwritten on the MAR with incorrect instructions like not taking with food when it needed to be taken at mealtimes to maximise the effectiveness of the medicine.