Richard House 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 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.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service lacked a consistently proactive and open learning culture that supported reflection and continuous improvement.

Systems were in place to record incidents and concerns; however, these were not consistently used to support learning or reduce the risk of recurrence. Information from incidents, including falls and medicines‑related concerns, was not always used to inform changes in practice or shared in a way that supported learning across staff teams.

Staff understanding of how learning from incidents was embedded into daily practice varied. While some staff were familiar with reporting processes, there was limited evidence that learning from safety events was routinely discussed, reflected upon or reinforced through changes in care delivery. This reduced opportunities to improve safety and promote consistent standards of practice.

Relatives described repeated issues occurring over time and did not feel assured that concerns led to sustained learning or improvement. This indicated that learning from incidents and feedback was not always embedded or translated into consistent changes in practice.

Systems to support safe pathways and continuity of care were not always effective, which affected how well care was coordinated. Information was not always shared effectively to ensure people received safe and continuous care, particularly when people’s needs changed. Care records and handover information did not consistently show that changes in people’s risks, health or support needs were clearly communicated to all relevant staff. This reduced assurance that care was reliably handed over and followed through.

Feedback from external health professionals further highlighted weaknesses. There were longstanding concerns about management instability, staffing pressures and limited clinical oversight, which affected escalation and timely action. Health professionals reported instances where deterioration, pressure care needs and changes in people’s conditions were not identified or acted upon promptly, and care plans did not reflect current risks or needs. Actions agreed following visits or reviews were not consistently completed or communicated, often requiring repeated follow‑up from professionals. This reduced assurance that care was coordinated effectively and that agreed clinical actions were reliably implemented.

Arrangements to recognise and escalate safeguarding concerns were not always applied consistently or in a timely way. Care records and daily documentation did not always show that potential safeguarding risks were recognised and acted upon appropriately. This increased the risk that people were not adequately protected from harm or neglect.

Although the provider had arrangements in place for reporting safeguarding concerns, staff understanding of when concerns required safeguarding escalation was inconsistent. In practice, safeguarding risks were not always clearly recognised or escalated, which limited assurance that concerns were consistently identified, addressed and followed through.

Relatives raised concerns that contributed to safeguarding risk. Some described occasions where people experienced repeated unmet needs, distress or delays in receiving care such as people being left soiled or in bed for prolonged periods, call bells going unanswered for extended periods and people not being checked on until late in the day. There were examples where health concerns, falls and injuries were not recognised, documented or escalated promptly including wounds becoming infected and deterioration only being identified after relatives intervened. Some relatives also reported repeated concerns about missed personal care, poor hygiene and medication issues. In several cases, relatives stated that action was only taken after they raised concerns themselves rather than concerns being proactively identified by staff. This reduced confidence that safeguarding risks were consistently recognised, escalated and addressed by the service.

The provider demonstrated appropriate use of Deprivation of Liberty Safeguards (DoLS.) Where people were subject to continuous supervision and control and not free to leave, applications had been made and authorisations were in place. Records showed that restrictions were linked to assessed needs and reviewed, with consideration given to least‑restrictive practice.

Improvements were implemented following inspection feedback, indicating that safeguarding risks were not consistently identified or addressed proactively prior to the inspection.

Care records did not always evidence meaningful involvement of people, or those supporting them, in decisions about managing risks associated with their care. For example, a person was observed being supported to eat by staff despite their care plan stating they were independent when eating. The care plan did not reflect the person’s current needs or identify associated risks, and there was no evidence that conversations had taken place with the person to explain the risks, discuss changes in support needs or agree how support would be provided safely. In addition, the person was observed being supported to eat in a laid‑back chair, which was not consistent with information provided by relatives about the positioning required to support safe eating. This increased the risk of unsafe support and highlighted further inconsistency between care delivery and known guidance about the person’s needs.

Following feedback, the provider updated the care plan to reflect the person’s need for assistance with eating and provided clearer guidance to staff. However, there was no evidence the person was actively involved in this discussion, that risks were explained to them, or their preferences were explored and agreed to manage the risks. This limited assurance that care plans consistently reflected a shared, person‑centred understanding of how risks would be managed safely while respecting people’s choices.

The provider generally provided an environment that supported people’s safety; however, some environmental risks and arrangements did not consistently protect people’s dignity or reduce the risk of harm.

Communal and dining areas were well presented, with appropriate space for mobility. However, some aspects of the physical environment needed further review. For example, window restrictors in communal areas appeared secure but were not fully tamperproof, and loose fixings were identified in one area. These issues required clearer risk assessment and timely action to ensure window safety measures were fully effective.

Environmental issues within the kitchen area were also identified. For example, fixtures requiring repair, including a tap running continuously, had not been addressed at the time of inspection. Some kitchen equipment required a professional deep clean, and waste‑oil storage presented a potential spill risk due to containers nearing capacity. These issues increased environmental risk and did not fully support safe operation of the area.

Following feedback during the inspection, the provider took action to address several of these concerns, including arranging a professional kitchen deep clean and progressing maintenance repairs.

Staffing arrangements were not always sufficient or well matched to people’s needs to ensure safe and effective care. Observations and feedback indicated that staffing pressures affected care delivery and people’s experience of care, particularly at busy times and overnight.

Staff raised concerns that there were not always enough staff on duty, especially at night and at weekends. They said staffing numbers did not always match how many people were living at the service or how much support people needed. This included not always taking into account people who needed more support because of dementia or physical health needs.

Staff described the impact of staffing pressures on people’s access to timely care. Concerns were raised that when staffing levels were low, some people who required two staff and equipment could not always be supported promptly because only one staff member was available. This increased the risk of unmet needs and unsafe care delivery.

Periods of limited staff presence in communal areas meant people were not always supervised or supported in a timely way, increasing the risk that needs went unnoticed until people or their relatives sought help themselves. Feedback from relatives supported these concerns. A relative told us, “There are not enough staff and I do hear call bells and alarms going on for some time.” Another relative said they sometimes had to hunt down staff when assistance was needed.

Core training requirements were in place; however, training and development arrangements were not always sufficient to fully support staff in their roles. Some staff reported they had not received appropriate role specific training, supervision or support for responsibilities they were expected to carry out, including supervising others or managing performance. This limited staff confidence and reduced assurance that staff were consistently equipped with the skills and knowledge needed to deliver safe care.

Recruitment practices were generally followed and provided some assurance in relation to safe staffing. Following feedback, the provider identified the need to improve training and role clarity for staff with additional responsibilities and took action to increase staffing numbers to improve capacity to meet people’s needs safely.

Infection prevention and control (IPC) practices were not applied consistently to reduce the risk of infection. The home was generally clean; however, standards of cleanliness were not consistent across the service. Some areas were affected by malodours, indicating that cleaning was not always carried out thoroughly or promptly. Records to demonstrate enhanced or targeted cleaning arrangements were not always in place, which limited assurance that infection risks were being effectively managed.

During outbreaks, there was limited evidence to show that enhanced cleaning measures were clearly documented or consistently implemented. Relatives raised concerns about communication during outbreak periods and said they were not always confident they had been given clear information to help reduce the risk of infection spreading. This increased the risk of infection transmission and reduced assurance that effective IPC controls were in place.

Relatives reported skin rashes and wounds that later became infected. In some cases, concerns about infection or skin integrity were identified by relatives rather than through routine monitoring, which reduced confidence that early signs of infection were consistently recognised and acted upon.

Following feedback, the provider took action to improve IPC, including introducing enhanced cleaning arrangements, strengthening housekeeping oversight and reviewing care plans to better reflect infection and skin‑integrity risks. These actions were implemented in response to inspection feedback, indicating IPC arrangements were not sufficiently effective at the time of inspection.

Medicines were not managed safely or administered in line with prescribing requirements. Records showed that prescribed medicines were not always available on site when required, which led to repeated missed doses. Some people experienced prolonged periods without essential medicines due to stock not being available. This included medicines for managing long‑term health conditions, increasing the risk of avoidable harm.

Medicines were not always administered as prescribed. Records showed that doses of important medicines were omitted for reasons such as the person being asleep, without evidence of timely follow‑up or re‑attempts. This included time critical medicines, where delays or missed doses increased the risk of deterioration in people’s health.

Errors and inconsistencies were identified within electronic medicines administration records (eMARs.) In one case, a prescribed medicine was removed from the active eMAR in error and was not administered for a period of time, despite remaining available on site. This was not identified promptly through checks or monitoring.

Controlled drugs were not consistently managed safely. Expired controlled medicines were found stored alongside in‑date stock, and some controlled drugs had not been correctly recorded in the controlled drugs register. This increased the risk of medicines being used incorrectly and limited assurance that appropriate controls were in place.

Following feedback, the provider took action to address immediate medicines related risks. However, these issues had been present prior to inspection, indicating that medicines risks were not always identified and addressed promptly through existing monitoring arrangements.