Dunraven House and Lodge

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 Good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of legal regulations in relation to safe care and treatment and safeguarding. At this assessment we found the service was no longer in breach of these regulations.

This service scored 69 (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.

Leaders had systems that ensured lessons from incidents were identified and shared across the organisation. For example, following any event, managers completed an incident form and produced reports which explored what measures to put in place to ensure the same incident did not occur again. These documents summarised best practice and were verbally shared with staff, ensuring knowledge gaps were addressed promptly and effectively. This meant the provider was able to drive improvements from learning.

Staff were actively encouraged to reflect on practice and to confidently escalate concerns. Staff told us they used team meetings as a way to share knowledge. Managers told us team meetings were an integral part of ensuring the service learnt from everyday care and support.

One manager invested time in reviewing external best practice guidance provided by the National Institute of Care Excellence (NICE) for medicines management, training and advanced care planning and allocated staff to lead in these areas. Comments from staff included “I was asked to take on activities at Dunraven and since stepping up, I have loved getting people involved in the community” and “As medicines lead, I make sure the service is up to date with policies and procedures”. This meant staff were confident in applying this best practice to their everyday work.

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.

Wherever possible, individuals were supported to review their own care documents and contribute to the ongoing changes to their care plans. When this was not possible, family members or chosen representatives provided input. These care planning documents enabled healthcare staff to gain an understanding of each person’s needs, helping to ensure continuity and consistency in care delivery.

For people who had frequent hospital visits, care planning documents demonstrated a joined up working approach. For example, collaborative planning showed the provider had shared a person’s digital records with the hospital once people had been asked for their consent. This meant all relevant professionals were able to work together to implement a discharge plan for the person.

The provider thought about how people would feel and what support they would need to move between providers. For example, a person had recently moved into the service from the community where they had been unable to support themselves with daily living tasks due to requiring additional support. Social workers were invited to visit the home, and the person received a transition plan. This meant the person was able to be supported to make improvements in their overall daily living. A manager confirmed they had worked closely with the person to support these improvements. Comments included “You wouldn’t recognise [person] now”.

Relatives were regularly invited to meet the provider before, during and after their family member moved to the service. One relative wrote: “I do not live locally but like to pop in when I am in the area to see everybody”. The provider told us, “Relatives can visit at any time”. This meant the provider was able to produce effective needs assessments to ensure people would receive care tailored to their individual needs.

The provider worked with people 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.

During our previous assessment we found shortfalls in relation to the safeguarding of people. During this assessment, we found the provider had addressed these shortfalls.

People told us they felt safe in their home and staff helped them stay safe. Two of the staff we spoke to were unable to describe and clearly identify safeguarding principles. Staff gave examples of how to keep people safe when providing care. All staff spoke confidently about recognising signs of abuse and how they would support people to stay safe. Staff told us, “I would not hesitate to raise a concern if I observed it”. People told us they felt safe. One person commented, ‘I am safe here, and I know who to speak to if I am not happy”. Managers confirmed this and had a record of all safeguarding concerns. The provider had informed the Care Quality Commission of safeguarding incidents where appropriate.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During our previous assessment we found shortfalls in relation to managing risk. During this assessment, we found the provider had taken action against these shortfalls. Risks to people’s health, safety and welfare had been assessed and action was taken to manage those risks. For example, people at risk of ligatures, addiction and accessing the community independently had a support plan and risk assessment in place. Staff demonstrated a good understanding of the risks and ensured care plans were updated regularly with people when their needs changed. There was a designated member of staff who updated people’s risk management plans within the service.

Another person experienced regular changes to their mental health and these changes were identified and assessed frequently to enhance the person’s safety within the home. One person told us, “Staff know when I am becoming unsafe and they support me to regulate my behaviours”. We saw staff supporting a person to ensure they were carrying their money safely prior to accessing the community. This meant people were actively involved in managing their risks.

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

The carpet in the main house on the first and second floors was frayed, with bare threads visible and damaged. This presented a trip and slip risk to people. People told us they avoided stepping on these areas. After our assessment managers told us replacing the carpet would be on the next phase of planned improvements to the home.

The provider had assessed the risk of fire. However, the fire risk assessment did not clearly identify new electronic systems and on-call facilities in the event of an emergency. Part of the providers mitigation of risk in the event of a fire was the use of on-call staff and an automated system. This meant key risks were not fully recognised, increasing the chance that staff would be unclear about how systems operated or who to contact during an emergency, a safe response would be delayed.

However, people had personal emergency evacuation plans which detailed hazards in the home and how to safely support people in the event of an emergency. These risk assessments noted what hazards to look out for in the future, as people’s needs changed.

The provider had recently started ensuring fire evacuations and drills were completed and they were including people in these evacuations. The provider had recently invested in new fire doors and an alarm system which was linked to the local fire service. All staff had completed online fire safety training.

The linoleum in the kitchen of the main house had lifted, creating large air bubbles and an uneven surface to walk on. We spoke to the provider who told us they were aware of a leaking pipe which had compromised the integrity of the kitchen floor. They told us they would be looking at fixtures and fittings as part of the second phase of their improvements.

Further, we saw staff supporting people to clean and tidy their rooms. People confirmed that staff helped them keep their rooms clean. One person said, “They always help me tidy up and help me hoover” and “we now have our own bedding and we wash these in the machines”. A manager told us: “Where possible, staff support people to do these tasks themselves”. These statements reflected the provider’s commitment to maintaining a safe and hygienic environment.

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

People told us they received consistent staff support and that they had built positive relationships with them. People told us there were enough staff to support them. Comments included “There is always someone around to help me” and “I have my favourites, I feel younger staff are more engaging, but I like everyone”.

Managers told us they did not use agency staff to cover shortfalls because they did not want people to be supported by unfamiliar staff. This meant the provider ensured continuity in service for the people they supported and ensured people received support from staff they knew well.

Pre-employment checks had been completed for staff before starting work. New staff received an induction, including shadowing experienced staff. Staff told us they received regular training, supervision and an annual appraisal. This ensured a competent and safe workforce when supporting people.

Staff had received mandatory training in learning disability and autism awareness and were able to demonstrate how they would appropriately meet people’s needs,

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The home was in general clean and tidy, however, we found that some areas of the kitchen and the equipment used weren’t clean which we informed the provider about. There was a risk of the spread of infection and bacteria due to mould food, and unsafe storage of food. Following our inspection the Food Standards Agency completed an inspection and rated the hygiene standards as ‘very good’.

Following our feedback, the provider informed us they had plans to refurbish the kitchen area.

Staff completed infection prevention and control (IPC) training and told us they had access to all the personal protective equipment they needed. We saw a cleaner cleaning windows and hoovering communal areas. Managers told us people were encouraged to clean and tidy their rooms and offered staff support if needed.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their medicines support, including when changes happened. People told us staff provided good support for them to take their medicines and told us what they take and why they take it. Staff had completed training in the safe management of medicines and leaders regularly observed their practice. Medicines audits were completed to ensure staff knew how to dispense and administer medicines safely.

Conditions within people’s Deprivation of Liberty Safeguards (DoLS) relating to regular reviews of medicines had been met by the provider. The provider had ensured they evidenced requests to the GP for medicines reviews. Changes in medicines were listed on the provider’s medication audits.

Leaders undertook monthly medicine reviews of all people. Findings were then discussed with staff and measures to support people to be compliant with medicine were explored. For example, managers told us one person regularly told staff they would take their medication later. Concerned they would forget when they were in the community, staff discussed this trend and developed a way of supporting the person differently by ensuring a checklist was completed prior to leaving the home.

People told us they were happy with how their medicines were managed Medicine errors had been recorded and escalated in line with the provider’s policies and procedures. Each person had a comprehensive medicines risk assessment, along with body maps for emollient application and clear guidelines to support safe administration. Medicine Administration Records (MAR) showed all prescribed medicines, including topical creams, were administered as required. This ensured people received the correct medicines at the right time, promoting safer care delivery.

However, people’s ability to manage their own medicines had not been individually assessed, for example, people who had capacity had not been given opportunity to manager their own medicines and medicines were still distributed from a shared medicines trolley. This meant we were not assured people who could do so, were being supported to independently manage their own medicines. Managers told us they were in the process of organising one person to be supported to self-administer.