Restgarth 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. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of regulations in relation to people’s safe care and treatment, staffing, recruitment and management of the service.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Prior to the inspection we had received information about one person being left for a long period of time without any support for continence care. This was not dignified and had put them at risk of developing skin damage. A manager had addressed the issue at the time, appropriately raised a safeguarding alert and discussed the importance of continence care with staff. Despite this we identified further incidents of this person, and others, being left for long periods of time with no support for continence care. This demonstrated opportunities to learn and improve practice had been missed.

External health care professionals had provided equipment for one person to minimise the risk of them developing skin damage. This had not been used as advised, staff reported this was because the equipment was faulty. However, records showed this was not correct, and the equipment had not been inflated correctly.

Following the inspection staff checked people’s skin and identified 6 people with redness which, according to one of the supporting managers, appeared to be due to poor continence care. This demonstrated the failure to embed good practice when things had gone wrong had put people at risk of avoidable harm. We shared our concerns with the local authority.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Systems to monitor people’s safety were ineffective. Daily records highlighted when people had not received support in line with care plans. However, no-one had oversight of the records, and no action was taken in response.

Care plans were not up to date or complete. One person had been identified as being at risk of weight loss by a dietician in May 2025 and the care plan stated they should be provided with 3 balanced meals per day and offered regular snacks. Daily notes showed they had not eaten breakfast for 6 consecutive days between 19 September and 24 September 2025. On 18 September they had not eaten breakfast until 12:16 pm. On the 19, 20 and 21 September 2025 they had not had any lunch. There was no guidance for staff on how they might encourage the person to eat. There were no records to show regular snacks were offered. The care plan directed staff to weigh the person every month. This had not been done for the past 2 months.

However, people’s needs were assessed before they came into the service. Assessments were completed by senior managers from the provider’s sister homes.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People were not safeguarded from poor and inappropriate care and opportunities to improve people’s experiences following safeguarding concerns were missed. A senior manager had raised a safeguarding concern when they had identified one person had been left without support for a long period of time. This incident had been discussed with the staff team and highlighted as an example of poor care. However, during the inspection we observed the person, and others, had again been left without support for extended periods. This demonstrated actions taken to minimise the risk of reoccurrence had been ineffective and meant people were exposed to ongoing risk of harm.

Training records showed one third of the staff team were not up to date with safeguarding training. Staff were not aware of the organisation’s whistle-blowing policy. However, they were able to describe what they would do if they had any concerns.

When safeguarding concerns had been identified by managers these were reported to the local authority and CQC as required.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were not all up to date and did not provide staff with accurate information on how to keep people safe. One person’s care plan highlighted 14 risk assessments as due for review.

Some people had risks associated with their behaviour which had not been documented or mitigated. For example, a manager told us one person sometimes took items from other people and would often pick up items of cutlery and walk around with them. This put the person and others at risk. There was no risk assessment in place. There was no guidance for staff on how they could mitigate the risk and help ensure people’s safety.

Some people had air mattresses to mitigate the risk of skin damage. We checked the settings for 3 of these mattresses. One was set to accommodate a weight of 130kg. The person’s last recorded weight was 95.7 kg. however, they had not been weighed since March 2025. The other two mattresses were of a different type and were set as medium. Staff did not have access to the manufacturer’s manuals so they would not know what the setting should be.

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

Personal Emergency Evacuation Plans (PEEPs) had been completed. However, information in many of them was either inaccurate or incomplete. Some of the PEEPs did not contain a room number to highlight where that person was. Others referred to people who were no longer using that particular room.

Water temperature checks were not being carried out. A member of staff told us this was because, since moving from a paper-based system to an electronic one, there was no system for recording the temperature. They told us it was not important as the water temperature was regulated by thermostatic mixing valves. However, regular safety testing should be completed to ensure the equipment remains effective and water temperatures are within the recommended range.

Other safety checks were completed. For example, fire extinguishers, hoists and a stair lift were regularly serviced. Fire drills were completed, and fire doors and emergency lighting were checked as required.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The service was short staffed, and a recruitment process was on-going. We analysed staff rotas for September 2025 and found staffing levels fluctuated significantly. For example, on Saturday 6 September there were only 4 staff working during the day whilst on Saturday 13 September there were 9 staff on duty. There had been no significant changes in the needs of people using the service between these dates. This indicated staff numbers were not always sufficient to meet people’s needs.

Rotas showed some staff were working excessive hours. We identified one occasion when a member of staff had worked a waking night shift due to staff sickness. They had also worked through the day and so had completed a 24 hour shift. This meant they may not have been able to provide quality care.

There were only 2 members of staff working during the night. Six people were cared for in bed and all required support from 2 members of staff when receiving personal care. This meant staff might not be available to respond to people’s needs quickly. Staff told us people’s beds often needed changing in the mornings as they were wet. This indicated people were not effectively supported with continence care during the night. Following the inspection the provider told us they had increased staffing numbers, including at night.

Due to vacancies in the kitchen, care staff were covering shifts preparing meals. This included the deputy manager which impacted on their ability to oversee the service. This was significant as there was no manager in post. Managers from the provider’s sister home were supporting the service but were not present on a daily basis.

There were gaps in staff training; 14 of the 28 members of staff employed had completed less than 75% of the required training. Two members of staff who were working in the kitchen, did not have in date Food Hygiene training. Following the inspection the provider told us they were arranging training updates for all staff.

Systems to ensure staff were suitable for work in the sector were not robust. One member of staff had received a negative reference. This had not been discussed at interview; there was no risk assessment to set out how the risk could be managed. Another member of staff had only provided references from past colleagues and not from a previous employer.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The service employed housekeepers and laundry staff. Throughout the inspection we observed housekeeping staff were busy, cleaning schedules were completed daily and communal areas were clean and tidy. However, the kitchen was dirty, the floor was sticky underfoot and the areas beneath kitchen units had not been swept. There was no evidence of scheduled deep cleans of the area to ensure all parts of the kitchen were clean. A member of staff told us the kitchen had not been deep cleaned for ‘about a year.’

We observed staff administering medicines. They did not wash their hands before and after giving medicine which put people at risk of infection.

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

Medicines must be stored within specific temperature ranges to maintain their safety and effectiveness. Temperature records showed that readings taken throughout September had exceeded 25°C on 27 occasions. The senior manager told us they were aware of this issue, and the medication room was not “fit for purpose”. However, no actions had been taken to minimise this immediate risk to ensure medication was stored safely.

Some people were prescribed medicines to be taken ‘as needed’ (PRN). Information to direct staff on when and how these medications should be given and any associated side effects (protocols) were not available to staff. We asked a senior manager for the PRN protocols and the information received had not been reviewed recently and was not available to staff.

The care plan for one person listed their medications, however this differed from the information on the electronic medication administration record. This meant the care plan was not up to date, and staff were not provided with accurate information.

Staff received training in the administration of medicines, the provider’s medication policy stated each staff member responsible for administering medication should complete an annual competency observation. We reviewed the staff files and found this had not been completed. The provider had not ensured staff were able to administer medication safely.

During our inspection we observed staff administer medicines which required stricter controls. These are known as Controlled Drugs (CD’s). Staff were seen to sign the CD register before administering the medicine. This was not in line with best practice guidance or the organisation’s policies and procedures which clearly stated staff should sign after the medicine was given.