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 Inadequate. 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.

At our last assessment, the service was in breach of legal regulation in relation to people’s safe care and treatment. At this assessment enough improvement had been made and the service was no longer in breach of this regulation.

This service scored 59 (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 mostly had a proactive and positive culture of safety based on openness and honesty, however improvements were still required. Leaders did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had been responsive to feedback from our last assessment and made some improvements at the service. However, there remained a number of areas that required further development. For example, there were some short falls in relation to incident management as reviews of incidents were not being completed. We found an incident of potential unsafe practice by staff that may have put a person at risk of potential harm. The lack of managerial review of incidents resulted in a missed opportunity to review the incident, complete investigatory actions and ensure safe practice. We raised this with the provider who immediately updated their systems and internal incident management policy.

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.

Records were in place to support safe transitions and provide external professionals with essential information. For example, personal emergency evacuation plans were available to staff and emergency service personnel in the event of a fire or other emergency situation, and this information was readily available on the doors to people’s private rooms. People’s Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms were available in the medicines room to support with emergencies and interactions with visiting health professionals. These are a personalised document that records people’s clinical preferences and care wishes if they cannot communicate in an emergency. People and their relatives told us the service supported safe transitions.

The provider mostly worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff mostly concentrated on improving people’s lives while protecting their right to live in safety. However, the provider did not always share concerns quickly and appropriately to ensure people’s safety.

People were not always protected by effective safeguarding processes. One person displayed signs of potential harm and the provider failed to identify these concerns and notify the appropriate authorities. This put the person at continued exposed risk of potential harm. Once awareness of the risk had been escalated, the provider then took appropriate action to investigate the safeguarding concerns and worked alongside health care professionals and the local authority to ensure people’s safety.

People told us they felt safe. One person said, “It's my home I feel secure and if I fall there's always someone there.” Most people’s relatives also told us they felt people were safe. One relative told us, “Yes people are safe. They all have buzzers. They help [relative] and guide them.” However, 1 person’s relative was concerned for their family members safety and described a lack of continuity of care at the service.

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 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. The provider mostly followed the principles of the MCA and had systems in place to track and monitor when a DoLs authorisation was in place.

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

Risks related to people's daily care and treatment were mostly well-managed, but further documentation improvements were required to ensure consistency. People were repositioned as required to minimise risk of developing pressure related injuries, and wound care management was safe and effective. However, care plans did not always contain sufficient detail to ensure staff had access to detailed up-to-date guidance on how to provide effective and safe person-centred care. For example, there was limited information in a person’s care plan describing how staff were to support with mobility. Staff told us they were supporting them with an assisted stand, but there was no description of this within the care plan or risk assessments. This meant the provider could not be fully assured all staff were using the appropriate technique in a consistent manner. Another person’s care plan care plan stated staff were to apply a barrier cream to an area of their body. However, the care plan was not updated following the development of a pressure injury, meaning further precaution was required to ensure the cream was used safely. This meant staff did have access to up-to-date guidance to manage this risk safely.

People and their relatives mostly told us that risk was managed well at the service. One person described to us how they experienced a bad fall at home and now felt they were safer living at the service with the supervision and support of staff. One relative told us, “They [staff] take their responsibilities very seriously and they are always on the ball."

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Mobility equipment was in good working condition and was visibly clean. People were mostly protected from risks related to the environment, however this was not always consistent. For example, risks related to a freestanding wardrobe in a person’s bedroom had not been assessed. We raised this with the provider, and they assured us it would be secured to prevent risk of injury. A garden area was accessible for people to use but was not free from risk. A wooden fence was lobsided and not secure, creating a potential risk of coming loose under weight and causing injury. A wooden decking area was not stable and moved when walked on, creating a potential risk of trips and falls.

Most people and their relatives felt the environment was safe and well managed, and people were supported using mobility equipment safely. One relative told us, “They [staff] use a hoist from bed to wheelchair. And they [staff] always explain what they are doing to him.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

During our on-site inspection there were plenty of suitably trained staff on hand to ensure people's daily needs were met in a timely manner. Staff worked at a relaxed pace and did not rush people. People and their relatives mostly spoke positively about staff and indicated that they met their needs in a timely way. Dependency tools were used to calculate the number of staff required for each shift and staffing rotas were in place to ensure these requirements were met. Staff received training relevant to people's needs.

We received mixed feedback from people and their relatives about the staffing numbers. One relative said, “Whenever I visit during the daytime, there are always plenty of staff around.” Whereas one person told us, “When I first came to service staff had more time to talk to you. There are less staff these days."

Safer recruitment checks were in place to ensure staff were suitable for their role. Recruitment files were in the process of being audited and reorganised to ensure the necessary paperwork was in place and easily accessible, but further work in this area was still required.

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.

Staff used personal protective equipment (PPE) when required and suitable stocks were available throughout the service. Leaders at the service assessed staff competence with hand washing and the safe application and disposal of PPE. Hand wash facilities and antibacterial hand sanitizer were available throughout the service and were suitably stocked. Bathrooms and washrooms were clean and tidy and waste bins had foot operated lids that were in full working order.

The provider mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, further improvements were required to ensure consistency and full compliance. Staff involved people in planning, including when changes happened.

Significant improvements in relation to medicines management had been made since our last assessment. In particular, the management of people's as and when required medicines, which were now manged safely. Additional resources and staff had been put in place by the provider to ensure the safe management of medicines moving forward. However, further developments were required to ensure consistency and full compliance. For example, topical and bottled medicines were not dated when opened. This meant the provider could not be fully assured that these medicines were being used within manufacture guidelines and remained safe for use. The controlled drugs book was not being checked in line with the providers policy. This meant staff were not following the providers guidelines for the safe monitoring of these medicines.

People received their prescribed medicines in a timely manner. Time critical medicines were safely managed and staff understood how to address and raise any medicines related concerns. Medicines records were accurate and well maintained. Auditing processes were completed to promote safe medicines management, however these had not identified the afore mentioned shortfalls.