Housing 21 - Rowan Croft

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 remained the same. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 demonstrated a positive learning culture, with staff encouraged to reflect on practice. Lessons learned meetings took place and incorporated learning from service, provider and national incidents. Accidents and incidents were monitored across different systems. The manager recognised the need to improve integration between these systems and told us work was underway to address this.

Staff worked effectively with partner agencies to support safe systems, pathways and transitions.

The manager told us they aimed to meet people before admission and encouraged joint discussions with the housing officer. When people were admitted to hospital, staff communicated proactively with hospital teams and GPs about medicine changes and discharge planning. Professionals gave positive feedback about the quality of communication with staff.

Whilst a safeguarding system was in place, some improvements were needed to strengthen safeguarding processes.

Whilst staff consistently reported safeguarding concerns to the local authority, which demonstrated they understood their responsibilities and acted to protect people, a small number of notifications had not been submitted to CQC in accordance with regulatory requirements. This meant CQCs oversight was limited; however, the manager recognised this and told us they would review their systems to ensure notifications were submitted correctly going forward.

Staff had completed safeguarding training and raised no concerns about practice at the service. People told us they felt safe, with one person saying, “There’s not a single dodgy staff member, they are excellent.”

Whilst a system was in place to manage risks, improvements were needed to strengthen risk management processes.

Risk assessments supported staff to understand people’s needs; however, some required further detail or updating. For example, assessments following falls were not always reviewed, pressure area risk assessments were not always accurate, and risks relating to people’s specific health conditions required additional information. Despite these shortfalls, we did not see any negative impact on people’s safety.

There was a stable, knowledgeable team who knew people well and recognised when their needs changed. People and relatives told us staff responded appropriately when risks or health needs altered, which helped maintain people’s safety and wellbeing.

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

People and relatives told us that the environment met people’s needs. A relative said, “It is great, far better than a care home. There is plenty of room to move around; they have a restaurant, nice lounges, and it is always clean, it doesn’t look tatty – it is a good place.” One person raised a concern about the onsite bath being out of order, but they had been offered alternative bathing facilities, whilst the bath was being fixed. Communal spaces were accessible and people had the option to use gardens, lounges and shared activity areas.

Whilst a system was in place to ensure staff were trained, some improvements were needed to strengthen training provision.

Staff had completed core training and demonstrated good knowledge of people’s day‑to‑day needs. However, they had not completed formal training on specific health conditions to fully support people’s individual health needs such as diabetes. Although formal training had not yet been undertaken, staff had received informal guidance and support from relevant health professionals, which helped strengthen their understanding and practice.

We did not see any negative impact of this shortfall on the quality or safety of care. People and relatives told us they felt staff were well trained and competent. One relative said, “A lot of the staff have been there a long time and are passionate about their jobs, they have a good attitude.” Another relative told us they felt some staff would benefit from further dementia training to increase their confidence in this area.

There was a stable staff team, along with appropriate staffing levels and safe recruitment practices, which meant people received consistent care.

The provider assessed and managed the risk of infection.

The service was clean and well maintained. Staff had access to appropriate personal protective equipment. People and relatives did not raise concerns about infection control and hygiene practices. One relative told us, “It’s excellent, the flats are very nice, clean and warm, we have no complaints”.

Whilst a system was in place to manage medicines, some improvements were needed to strengthen the recording of medicines.

Staff did not record the quantities of medicines received, instead they documented the number of days medicines should last. When this was calculated incorrectly, it could lead to confusion about stock levels. Some care plans, medicines administration records, guidance for ‘as required’ medicines and topical patch records also required more detail. The manager told us these issues would be addressed.

Despite these shortfalls people and relatives told us they had no concerns about how their medicines were managed and we did not see any negative impact from the issues identified.