Archived: HF Trust Rendle 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 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.

The service was in breach of regulations in relation to the oversight of the service.

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.

Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff had supported people to identify goals and skills they wished to develop. Information about what worked well and what did not work when supporting people to do new things was not always recorded. This information can support staff to develop consistent approaches and improve outcomes.

Processes to learn from incidents were not always followed. Accidents and incidents were recorded and reviewed so any trends or patterns could be identified. The records lacked detail, this meant analyses might not identify potential triggers or patterns of behaviour. We saw an incident had recently been recorded when one person made unwanted physical contact with another causing some distress. However, the detail about where and why the incident had occurred was not specific.

A manager told us staff had opportunities for informal debriefs following any incident, although these were not recorded. A member of staff said they did have meetings but not necessarily following incidents. This meant the details of, and circumstances surrounding incidents might be forgotten and opportunities to learn lost.

Feedback to staff of any changes to people’s care following an incident were communicated in handovers and staff meetings.

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.

The service communicated with other agencies to help ensure continuity of care. Hospital passports contained essential information to inform hospital staff how best to support people if they needed to be admitted. One person was due to have a planned hospital admission and the deputy manager had contacted the hospital’s learning disability team to support the process and ensure the person’s needs were fully understood.

The deputy manager described how they had worked with another provider when a person living at Rendle House had moved to be closer to family. They told us they had supported the new provider to furnish and decorate the bedroom so it closely resembled their bedroom at Rendle House. This had helped the person to feel comfortable in familiar surroundings.

The provider did not always ensure people were supported in line with the Mental Capacity Act. Capacity assessments were not consistently completed. Records to evidence restrictions to people’s liberty were reasonable, proportionate and in their best interest were not always completed. Staff ensured people were protected from all forms of abuse and the provider shared concerns quickly and appropriately.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

The service had not consistently operated in line with the requirements of the MCA, capacity assessments had not always been completed as required. For example, one person had a Deprivation of Liberty Safeguards (DoLS) which authorised specific restrictions on their liberty in order to keep them safe. Following changes to night staffing arrangements the service had informed the DoLS team they wished to add a further restriction, namely an audio monitor to alert staff if the person was awake during the night. No associated capacity assessment or best interest record had been completed prior to contacting the DoLS team. Managers told us the monitor was not in use as it was no longer required.

When specific decisions had been made on behalf of people it was not always clear the decision was proportionate and in the person’s best interest. A decision had been taken that one person would not undergo a particular health examination. The decision had been discussed in a telephone call with a GP. There was no record of the conversation to evidence the decision had been taken in the person’s best interest.

Following the inspection action was taken to address these issues.

Staff had completed training in safeguarding and the MCA. They understood their responsibilities under safeguarding and reported any safety concerns to management. Staff were confident any concerns they raised would be dealt with but were aware how to escalate issues outside of the organisation if needed.

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.

Risk assessments had not always been completed when risks were identified. Some people could put themselves and others at risk when they were agitated and unable to manage their emotions. There was a lack of guidance for staff on how they could support people at these times to help ensure all remained safe and any anxieties were dealt with. Following the inspection, risk assessments were developed in these areas.

One person had equipment to keep them safe. Staff were able to describe how this was regularly checked and managed to help ensure it remained safe. However, there were no associated risk assessments to help inform staff who could have been less familiar with the person’s needs.

Relatives told us they had no concerns about their family member’s safety. Staff were knowledgeable about people’s needs and supported people to live full lives while managing any identified risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Checks of utilities and equipment were regularly carried out by external contractors. Staff completed weekly and monthly checks such as water temperatures and fire safety equipment. One person was also involved in completing health and safety checks. Involving people in managing their home can contribute to feeling a sense of ownership and belonging in their home environment.

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.

New staff were recruited safely and completed an induction before starting work at Rendle House. There were sufficient staff to meet people’s needs and enable them to take part in any pastimes or hobbies they enjoyed. Agency staff were sometimes used to cover gaps in the rota. The service had the information they needed to help ensure agency staff had the necessary skills and experience to support people living at Rendle House. Where possible the same agency staff were booked to help provide consistent care.

Staff received regular supervision and yearly appraisals. Staff told us they were well supported.

A training matrix showed staff had completed training in relevant areas including supporting people with a learning disability and autistic people. In addition, staff received training in Person Centred Active Support (PCAS). The training was underpinned by observations of practice to check staff were applying this training effectively.

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.

The environment was clean and tidy. Staff received training and were provided with appropriate protective clothing, such as gloves and aprons to use when carrying out personal care. Regular checks were made of the premises.

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

Medicine Administration Records (MARs) were kept to evidence people received their medicines as prescribed. However, handwritten additions to printed medicines records were not consistently signed and checked by a second staff member, contrary to best practice and the provider’s own policy.

Some people had prescribed creams and these were recorded on the MARs. However, the records were not consistently signed to show these had been applied. Some creams had not been dated when opened and expiry dates had not been noted. One person’s cream prescription stated it should be applied twice a day but the MARs showed it was only being used once a day. A medicine audit completed on 13 October 2025 had failed to identify these oversights.

Some people had medicines prescribed to be used ‘as required’ (PRN). There were protocols to guide staff on the use of PRN medicines. However, these were not always person-centered and did not direct staff on when these medicines should be offered.

Staff had received training in administration of medicines and were assessed as competent to provide support in this area. Following any medicine errors staff competencies were reassessed. People’s medicines were stored in their room to enable staff to support them in privacy when medicines were being administered.