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 Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

At our last assessment the service was in breach of legal regulation in relation to people’s safe care and treatment. At this assessment we found the provider had failed to make necessary improvements and remained in breach of legal regulation in relation to people’s safe care and treatment. At this assessment we also found the provider was in breach of legal regulation in relation to fit and proper persons employed.

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.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to and act on concerns about safety and did not investigate safety events. Lessons were not learnt to continually identify and embed good practice. During this assessment we raised concerns with the registered manager about people’s safety in relation to medicines, moving and handling and the environment. They failed to ensure sufficient action was taken to mitigate risk and people were exposed to prolonged risk of potential harm. For example, one person was left in a slouched position in a wheelchair for prolonged periods, the kitchen door was left open when no staff were present to ensure people’s safety, and medicines administrations were not completed in a safe and timely manner. Feedback from staff supported our findings. Some staff told us they did not feel the registered manager or the provider promoted a positive learning culture.

The provider did not always make sure care plans and other records were up to date to ensure 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 identified risk and demonstrate 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 always 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 lack of service oversight by the provider and the registered manager meant safety incidents and risks to people went undetected. This meant people were not always protected from the risk of potential harm. Despite our findings, people and their relatives told us they felt safe. One relative told us, “We are very happy with the service. [Person] is safe there and the staff are really nice.”

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. We found that the provider had DoLS policies and procedures in place. However, where people were subject to restrictions to keep them safe, details of the deprivation, the assessments supporting them and the duration they applied for, were not always clearly stated in people’s care records. For example, pressure sensors were in place for some people to alert staff when they mobilised. Assessment records did not always record the judgement for putting this equipment in place and did not always evaluate its effectiveness.

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. For example, people living with diabetes did not receive safe and appropriate care. Care records for one person did not evidence staff were responding to high or low blood glucose levels in accordance with their care plan, and the use of finger prick blood glucose monitoring was not always recorded. Staff we spoke with as part of this assessment did not always have sufficient knowledge on how to support people with their diabetes safely. One staff member said, “I’m not sure what to do if their [person] blood glucose levels are low.” Despite the findings of this assessment, feedback from people and their relatives indicated they felt risk was well managed at the service. One relative told us, “[Person] is safe. They have settled very well, and staff keep us informed about everything.”

The provider did not 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. For example, the kitchen door was left open when no staff were present in the kitchen, and people living with dementia were in the near vicinity. This exposed people to the potential risk of harm. Staff confirmed the kitchen door is sometimes left open. We also observed one person being supported in a wheelchair by staff without the use of foot plates. This exposed the person to potential risk of harm as their feet were dragged across the floor. Despite our concerns feedback from people and their relatives indicated they felt the environment and use of equipment was safe. One relative told us, “[Person] is at high risk of falls and so they are hoisted into a wheelchair or bed. The hoist is always available, and the staff are well trained. I have no concerns.”

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not 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. At times staff were rushed and were not always able to spend quality time with people. There was little engagement during meal service and people were often left without staff supervision or support. Staff were not always supported by the registered manager during daily service delivery. Feedback from staff supported our observations. One staff member told us, “We feel rushed during dinner service. People aren’t always having time to swallow their food.” Another staff member told us, “We are overworked. We don’t get enough time with residents. There’s often no time to talk to them. This doesn’t support people’s mental wellbeing.”

We received mixed feedback from people’s relatives. One relative indicated at times staff were very busy and rushed, whereas feedback from most relatives indicated they felt there were sufficient well-trained staff to meet people’s needs.

Recruitment processes were not effective. A staff member in a leadership position had not been interviewed for their role. This meant the provider could not be sure their training needs had been identified or that they had the support to be competent. Full employment histories were not always obtained, and in some instances, there were unexplained gaps in people’s work experience. This meant the provider could not be assured employed staff had the necessary skills and experiences.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The service was clean and tidy throughout, with only a few exceptions, such as visibly greasy extractor fan filters in the kitchen. Staff were observed using personal protective equipment, however this was not always removed and disposed of in accordance with best practice. We also observed unsafe infection prevention and control (IPC) practices during medicine administration. For example, we observed the medicines administrator putting boxed and topical medicines into their trouser pocket whilst supporting people who were isolating due to suspected influenza. This increased the risk of the spread of infection and put people at potential risk of harm. The providers policy lacked detail and did not support effective IPC. People’s relatives felt the service was clean and tidy. One relative told us, “The service is clean, comfortable and homely.”

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Time critical medicines were not suitably documented to ensure safe administration. For example, one person received support with medicines to treat Parkinson’s disease that needed to be administered at specific times throughout the day. There was no record of the time of administration. This meant the provider could not be assured this medicine was administered as prescribed to ensure effectiveness.

As and when required medicines were not administered as prescribed. For example, one person received paracetamol 4 times daily rather than when needed as prescribed. There was also no record of the time of administration or follow up to measure the impact of this medicine. This meant the provider could not be assured this person was protected from the risk of overdose and did not have sufficient information to review the effectiveness of this medicine.

Medicine records were not always completed by the staff member administering them, or at the time when medicines were administered. This meant records did not accurately reflect the medicines support people received, preventing effective oversight and analysis.

Medicines were not stored safely. There was no temperature monitoring in place for medicines stored in the managerial office. This meant people were at risk of receiving potentially spoiled or ineffective medicines. Topical medicines were stored in people’s bedrooms who were living with dementia without associated risks being considered by the registered manager.