Russell House

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 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, including the ways people’s medicines were managed.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a learning culture guidance document, which outlined the registered manager and staff’s responsibilities and ways they promoted a learning culture.

The care plan electronic monitoring system enabled the service to have an overview of accidents,Incidents and safeguarding’s to promote learning.Incidents were discussed at team meetings to reflect on the incidents and inform staff of measures taken to prevent a reoccurrence.

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.

People had a hospital passport in place, which was updated with any changes as they occurred. Staff supported people to appointments with records maintained of the outcome and follow up.

The service had access to on-site professionals such as Physiotherapists, a Speech and Language Therapist (SALT) and an Occupational Therapist. Appropriate and timely referrals were made with professionals and staff at the service working collaboratively to provide a joined-up approach to safety in the person’s care.

Relatives were happy with their family members access to medical interventions,reviews and therapy services input.They confirmed they felt involved in their family members care and were kept informed of changes in their health and well-being.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service had policies and procedures in place to safeguard people from abuse.Staff were trained in safeguarding with posters displayed to remind them of the process for reporting.Incidents of potential abuse were reported to the relevant agencies in line with safeguarding procedures.

Safeguarding was discussed at resident’s meetings with pictorial minutes provided of the meeting to promote people’s understanding.

Relatives told us their family members were safe and any concerns about safety were listened too and acted on.

We checked whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. We found systems were in place to monitor legal authorisationsa nd renewals were completed when required.

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.

Risks to people were not always identified and mitigated. A person who was a known choking risk and required staff supervision at meals was not consistently supervised. In the providers response to the draft report, they assured us the person required prompting and encouragement as opposed to direct supervision. This contradicted the person’s care plan which indicated the person was to be observed and had the potential to put the person at risk. Another person’s choking risk assessment indicated that the choking risk increases if Speech and Language Therapy (SALT) guidelines for food and drink preparation are not followed. However, it was not recorded what those were, to mitigate the risks to the person.

The risk assessments on managing people’s distressed behaviours did not outline how staff should safely manage verbal and physical aggression to keep them and the person safe.

People’s allergies were identified but not always mitigated. In one person’s care plan there was a contradiction as to whether they had an intolerance or an allergy to a food item. Another person was identified as having an allergy and if exposed was at risk of having an anaphylactic shock. Their care plan did not outline the symptoms of anaphylaxis. Following our feedback this was updated to include guidance for staff on the symptoms of anaphylaxis.

Moving and handling risks did not outline the specific equipment to be used for individuals. A person was a known risk of putting themselves on the floor but there was no guidance on how staff safely supported them off the floor. These practices placed people at risk of unsafe care and treatment.

In response to our feedback the provider took immediate actions to address shortfalls in their risk management.

Professionals involved with the service confirmed staff had a good knowledge of people. A professional told us of their involvement in a funding review. They commented, “As a professional looking in it was clear that staff knew the person so well, they were able to intuitively read the situation and respond appropriately but the written evidence to support this was not reflecting that. Occupational therapists worked with the team to educate them about the importance of what they document and shared some strategies to improve how they evidence the amazing work they are doing. I found the team all very engaging in the training and keen to improve the quality of their notes. We followed up a couple of times and found an improvement.”

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.

Environmental risks to people were not identified and mitigated.Free standing heaters and fans were in use without a risk assessment to promote their safe use.People had access to hand sanitizer and disposable gloves and the risk of ingesting those had not been considered.

Doors required to be locked such as the door to the electrics and laundry room upstairs was left open and unlocked.The doors to units were sticking and not always closing properly and the garden was insecure.The cupboard under the sink in the laundry room was left unlocked and contained chemicals which placed people at risk. The water temperatures in the laundry exceeded the safe water temperatures as is required, therefore the unlocked laundry room placed people at potential risk of scalding.

Window restrictors were in place. The provider told us they undertook monthly health and safety checks. However, there were not any separate window restrictor checks to ensure they remained in working order. Equipment was stored in corridors which had the potential to act as a hazard in an emergency.

In response to our feedback the provider took immediate action to address our findings, assess and mitigate the environmental risks.

Equipment such as the lift,fire and moving and handling equipment was tested and serviced. The water,gas and electric supplies were serviced at the required frequency.

The provider made sure staff received effective support, supervision and development. However, the rotas did not always reflect the required staffing levels were provided.

The service had a dependency tool in place which outlined the staffing levels per unit. However, some staff did not feel the staffing levels were always sufficient and gave examples where they felt it impacted people. In the team meeting minutes we saw staff had raised concerns that the required staffing was not consistently provided and staff were asked to return from activities early to ensure adequate staffing levels on the units. We saw in the rotas, occasions where staffing was reduced till 9 am. This was feedback to the registered manager and provider to assure themselves of the staffing levels.

Relatives felt the staffing levels were appropriate, consistent and teamwork was promoted.

The service had a Learning and Development policy and procedure which outlined the providers and employee responsibilities to training. It included an outline of the frequency of training. Staff had access to a range of training that was considered mandatory such as fire safety, first aid, moving and handling. They also had specialist training such as training in learning disabilities and autism, managing distressed behaviour, and epilepsy awareness training.

Staff had their competencies assessed in relation to medicine administration, hand hygiene and moving and handling. Whilst staff had online training on the use of equipment such as the life vac and EpiPen the provider had not assessed their competencies to be assured they were competent in performing those tasks in an emergency. We have asked the provider to assure themselves that staff have the required competencies for these tasks.

Recruitment files contained all required checks, such as a check for criminal convictions and uptake of references.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Areas of the home were not clean and hygienic. The kitchen and bathroom floors were stained and there was a build-up of dirt around dishwashers and edging of floors with the kitchen cupboards. There were rusty bins in bathrooms and in one bathroom the non-slip mat was badly stained. Kitchen cupboards in one kitchen had the trim loose and the cupboard door was damaged. Areas of work tops were damaged and could pose a cross-contamination risk.

On the first day of inspection the wall mounted hand sanitizers were empty and this did not promote good infection control practices. This was raised with staff, and the hand sanitizers were filled by day 2 of the inspection.

Fridges contained out of date foods and not all food opened was dated or labelled.

Frozen chicken and minced turkey was being thawed out in a bowl of water which placed people at risk of salmonella.

In response to our feedback the provider took immediate actions to address the level of cleanliness within the service and mitigate cross infection risks. On day 2 of our inspection, we found the service was cleaner and better organised.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Several people had their medicines mixed with yoghurt, for ease of swallowing. This was indicated on the medicine administration record (MAR) chart but not in the care plan. There was no record that pharmaceutical advice had been sought about mixing medicines with jam or yoghurt. One person was prescribed a medicine to take on an empty stomach however, this was administered with yoghurt. The lack of clinical advice regarding mixing medicines with food placed people at risk of ineffective treatment.

Many people were prescribed a medicine that has been in several patient safety alerts over the last few years. The staff were not aware of what patient safety alerts were and the provider had no evidence that alerts were being actioned. This placed people at risk and there was no governance in place to identify this risk.

A person had a life-threatening allergy which required treatment with adrenaline. The care plan did not contain sufficient information regarding the symptoms of the allergy that would warrant adrenaline treatment. On this person’s MAR, no allergies were listed however they had two drug allergies listed in their care plan. This was immediately rectified whilst on site.

Several people had their medicines administered via a special feeding tube. Although staff had received training on how to administer medicines this way, there was no specific documentation to outline the provider’s accountability, and responsibility of medicines administration for this delegated task. There was no evidence that competencies were assessed.

Room and fridge temperatures were recorded daily. Medicines were stored securely and there was good management of controlled drugs.