Radis Community Care (Oak Tree 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.

This is the first assessment for this newly registered service. This key question has been rated 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 safe care and treatment, the way people’s medicines were managed and governance at the service.

This service scored 50 (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 did not consistently demonstrate a proactive and positive culture of safety that was underpinned by openness and honesty. While concerns relating to people’s safety were listened to by management, we were not assured concerns were always appropriately investigated or acted upon.

Incidents and accidents were reviewed by the service, and referrals were made where required to support people’s safety. Some actions were recorded following incidents; however, records did not consistently demonstrate people’s care plans or risk assessments had been reviewed or updated in response to incidents. In addition, themes and trends were not always identified or analysed in a timely way to reduce the risk of reoccurrence or provide support and guidance to staff.

Staff received regular supervision, which provided opportunities to discuss learning needs and identify where improvements could be made to people’s care and support. However, where staff raised concerns and identified risks to people, there was a lack of follow up action.

Staff told us they felt informed about incidents and understood their responsibilities in relation to reporting concerns. The service used a communication book to provide daily updates for staff, which included changes to people’s needs and any actions required. This supported information sharing and continuity of care.

The provider did not consistently work effectively with people and relevant healthcare professionals to establish and maintain safe systems of care. They did not always effectively manage or monitor risks to people’s safety.

People had care plans and risk assessments in place; however, these did not always contain sufficient or accurate information to guide staff in supporting people with their individual needs. Information relating to people’s medicines, health needs and support requirements was not always consistent across documentation, which placed people at potential risk of receiving unsafe or inappropriate care.

Where healthcare professionals had been contacted in response to concerns about people’s health or wellbeing, care plans were not always updated to reflect the advice or guidance provided. In some cases, associated risk assessments had not been completed, and care plans did not clearly record the concerns raised or the actions required to support people safely.

The absence of accurate and up‑to‑date information meant staff did not always have clear guidance to support people’s needs. This also created a risk where people moved between services, such as admission to or discharge from hospital, as essential information about people’s health needs, risks and support requirements may not have been shared effectively or in a timely way.

The provider did not consistently work effectively with people and healthcare professionals to understand what being safe meant to them or how best to achieve this. Concerns were not always shared promptly or appropriately to ensure risks were managed and reduced.

Records reviewed showed some safeguarding concerns had been raised, however, the service was not aware of their responsibility to notify the Care Quality Commission of safeguarding incidents. In addition, safeguarding concerns were not consistently recorded on the service’s safeguarding log, which limited effective oversight. This meant we were not assured safeguarding concerns were consistently monitored, escalated or appropriately reported.

Where safeguarding concerns had been raised, information about the risks involved was not always effectively communicated to safeguarding teams or consistently incorporated into people’s care plans to guide staff practice. This meant staff did not always have clear guidance on how to support people safely. Incidents and accidents were recorded, and actions were documented to support people’s immediate safety. However, we were not always assured learning from incidents was embedded into practice to improve people’s ongoing care.

For example, one person experienced a choking incident. The service escalated this to healthcare professionals and instructed staff to stop supporting the person with eating. However, this person was unable to feed themselves, which meant the guidance was not appropriate or sustainable. Although learning identified the need to escalate concerns and involve relevant professionals promptly, no choking risk assessment was completed, there was no documented outcome from professional involvement, and staff had not received training in managing choking risks. This meant the risk of reoccurrence had not been effectively managed.

Staff had completed safeguarding training. However, where staff raised concerns about people, or staff themselves, who may be at risk, appropriate risk assessments were not always completed to support safe practice and safeguarding measures were not consistently implemented.

Relatives told us, they felt their loved ones were generally happy and described the care provided as good. However, they also shared areas where they felt improvements were needed to better meet their relative’s care needs and ensure risks were appropriately managed.

The provider did not consistently work effectively with people to assess and manage risks to their safety. Care plans and risk assessments did not always contain sufficient information to guide staff on how to support people safely and in line with their individual needs.

Risk assessments were not always in place for areas of known risk, including challenging support needs, refusal of care, use of bed rails, choking risks, skin integrity and diabetes management. This meant staff did not always have clear guidance on how to manage people’s healthcare needs safely, which placed people at potential risk of harm.

Where people declined or refused care and support, there was limited evidence staff explored people’s views to understand when or how they may prefer their personal care to be provided. There was a lack of analysis to identify patterns or themes in refusals, and limited evidence of follow up actions to ensure people’s needs were met.

Relatives told us, they were informed when there were changes to their relative’s care and support, however, they did not always feel their loves one’s needs were being fully met.

The provider had systems in place to identify and manage risks within the care environment. Where care plans identified the need for specific equipment, this information was recorded within the care documentation.

However, where equipment such as bed rails was in use, associated risk assessments had not always been completed. This meant potential risks had not been fully assessed or clearly documented. The manager told us they would take action to ensure risk assessments were put in place where required. People’s pendants were checked regularly for their safety, and this was well documented within people’s care notes.

Staff received training in health and safety and moving and handling, which was refreshed annually. The provider carried out spot checks to monitor staff practice and provide assurance care was delivered safely, and the environment was maintained appropriately.

The provider did not always ensure there were sufficient numbers of qualified, skilled and experienced staff to meet people’s needs. Staff received appropriate support, supervision and development. However, improvements were required to ensure staff had the necessary knowledge and skills to safely support people with specific health conditions.

The service supported people living with diabetes, however, staff had not received specific training in diabetes management, or dysphagia/choking training which meant they may not have had the required knowledge to safely support people with this condition.

The provider had identified issues such as missing documents within staff recruitment files and had introduced risk assessments and additional mitigating actions to manage these shortfalls. These included regular supervision, spot checks and competency assessments to provide assurance staff were suitable and able to carry out their roles safely, despite missing documentation.

Staff told us they had received dementia training during their induction, however, concerns from relatives indicated further refresher or more in‑depth training may be required. Relatives raised concerns, they did not always feel staff were adequately trained in dementia care or had a sufficient understanding of people’s individual care needs.

Staff received a comprehensive shadowing induction and regular supervision, which provided opportunities for support and discussion about their role. The provider carried out regular competency assessments to monitor staff practice and to ensure staff continued to have the skills and knowledge required to provide safe care.

The provider did not consistently assess or manage risks relating to the prevention and control of infection.

At the time of the inspection, we identified bedbugs were present in several flats within the building. The provider described the actions already taken and ongoing action to address the issue. Some care plans recognised this risk and included individual risk assessments. However, this approach was not consistent across the service, as not all people affected had a risk assessment in place, and the Commission had not been notified of the identified risk.

Relatives we spoke with told us they did not always feel their relative’s environment was kept clean. People told us, “The carer will sometimes put the duster around and give the flat a sweep,” which indicated cleaning support was not always thorough or consistently delivered.

Most staff had completed annual infection prevention and control training. However, some staff had not completed the required refresher training, which reduced assurance all staff had up to date knowledge to support safe infection prevention practices.

The provider did not ensure that medicines and treatments were consistently safe or met people’s needs, capacities and preferences. The manager felt confident there were no concerns with the medication management at the service, however, we found that medicines were not always safe.

We identified one person’s medicines were stored in a locked staff office, despite the person having capacity to make decisions about their medicines. There was no documented best interest decision or clear rationale to support this arrangement. The person’s daily records contained unclear and inconsistent information about medicines held within their home, which had not been identified through medication audits. Following the inspection, the provider put steps in place to ensure decisions were made in this person’s best interest.

One person had a medicine prescribed for use in emergencies to relieve chest pain. This person was receiving the medicine at times daily and experienced episodes of agitation. This had not been identified through the weekly medication audits in place. The service’s medication policy specifically identified this medicine should not be administered routinely.

We found one person’s documentation identified a recorded medicine allergy. Despite this, the person had been prescribed and administered medicines which contained this allergy for a short period of time. The manager told us they would take immediate action to address this with the GP surgery.

We reviewed several months of medication administration records and found medicines had been removed from one month to the next without a documented explanation. Audit records did not clearly demonstrate previous months had been reviewed or MAR charts had been checked against care plans or medication lists to ensure accuracy. Medicine documentation was not consistent across people’s information, therefore it was not always clear what people’s prescribed medicines were.

Medication audits had not identified issues relating to medicines prescribed on an ‘as required’ (PRN) basis. This may have been due to medication administration records (MAR) being handwritten, which is not considered best practice. PRN administration times were not consistently recorded on MAR charts, and some medication charts did not include all prescribed PRN medicines.

Where required medicine administration times had not been recorded, the service had identified these omissions, however, there was no documented action to show how these concerns had been addressed or how staff practice had been improved to prevent reoccurrence.

The medication policy stated the local authority medication policy took precedence. This created a potential risk staff may be unclear which guidance to follow, although the service’s medication policy itself was comprehensive.

Positive practice was identified within some documentation, which clearly recorded potential medicine side effects and provided guidance on how to escalate concerns. Where PRN protocols were in place, these were detailed and included information about side effects, with key information highlighted to support staff recognition.

Staff had received medicines training, and their competencies were assessed regularly, which provided some assurance of staff knowledge and practice. However, oversight and auditing did not identify the concerns we found during inspection which meant risks associated with medicines management were not always identified or effectively managed.