Ridgeway Court 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 new provider. 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 provider was in breach of legal regulation in relation to training as staff had not completed core training to ensure they had the skills and knowledge for their role.

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 was working towards developing a proactive culture of safety. However, staff did not always report safety events and these were not always investigated. Lessons were not always learnt to continually identify and embed good practice.

The provider and management team had implemented new systems to monitor incidents within the home. However, further time was needed to embed these. The systems included an electronic system which recorded all incidents, accidents, complaints and safeguarding. These were reviewed individually and monthly for patterns and trends. However, we found the analysis and outcomes had not always been recorded for all entries, and where some people had fallen more than once in a month, this had not always been considered in relation to how future risks for that person would be reduced.

Records reflected the learning from most of the incidents and actions that would be undertaken to reduce future occurrences. Staff confirmed learning was shared with them in most instances through team meetings, supervisions and training sessions.

Although the provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored, they did not always ensure the assessment process considered all aspects of people’s needs.

People’s presenting needs were assessed before they moved into the home and relatives confirmed they were asked for information about people’s preferences and care needs. However, we found for some people their additional needs were not always considered as part of this process. For example, where some people had learning disabilities and learning difficulties the assessment process did not consider ‘Right support, right care, right culture’ guidance in respect of these people and how their needs would be met in accordance with this statutory guidance.

Staff worked with social and health care professionalsto support people’s transition to the home and where needed made referrals when specialist input was needed.

The provider’s safeguarding systems were not always effective. The provider did not always share concerns quickly and appropriately.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is usually through MCA application procedures called Deprivation of Liberty Safeguards (DoLS). Applications had been completed as required and systems were in place to maintain oversight of all authorisations in place. We found due to a previous discrepancy on the provider’s monitoring record 2 people’s DoLS had expired. However, this had been addressed by the current manager and new applications submitted. Where people had conditions on their DoLS, there was limited evidence within people’s records to support how these were kept under review, or how they were being met. This meant the provider could not always demonstrate it was meeting its legal duties to comply with these conditions.

Although safeguarding incidents had been reported to the local authority, notifications had not always been shared with CQC in accordance with the provider’s policy. This included where people were at risk of self-neglect, and potential financial abuse allegations. A safeguarding tracker was in place to record and monitor safeguarding incidents reported. This included in most instances outcomes and learning from these.

People told us they felt safe when they were supported by staff. One person said, “I am safe here, there are staff around to check on me and keep me safe.” A relative told us, “I have no concerns at present I think staff keep [person] safe.”

Staff had received safeguarding training and demonstrated a good understanding around how to protect people from the risk of abuse. Staff told us if they had any safeguarding concerns, they would raise these with the provider.

The provider did not always work well with people to understand and manage risks. Staff told us they knew people well. However, some care documentation had gaps in recording and was inconsistent.

Most people in the home had sensor mats in their bedrooms. The manager told us this was due to people’s risk of falls. However, risk assessments were not always in place detailing this. We saw from people’s care records, the sensor mats were checked every 2 hours when people were in their bedrooms to ensure they were working. However, this also included during the night, which had the potential to disturb people’s sleep. Records did not show this had been discussed with people or their representatives to agree the management of this risk. The management team and provider were responsive to our feedback and were currently reviewing this.

Some people were at risk of malnutrition, dehydration and sore skin, and monitoring charts were in place to monitor these. However, the records we reviewed did not always reflect pressure relief was provided at the required intervals, fluid targets were met and food intake was not always accurate and clear. The provider had introduced an electronic system which monitored the completion of these records. The management team monitored this, and action was being taken to explore any discrepancies with the records. Where needed actions were taken to address staff performance.

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.

On the first day of our assessment, we found several health and safety concerns which had not been identified and addressed by the provider. This included 2 inappropriate window restrictors in people’s bedrooms, defective window blinds, stained commodes and worn items of furniture, stained and worn flooring. The provider sent us an action plan in response to all the areas we had identified, and immediate action was taken to address some of the high-risk areas such as the window restrictors.

Several areas of the environment were worn and required renewal. The provider had plans in place for an extension, and a refurbishment plan was in place. The provider told us they were reviewing best practice guidance to ensure the building was suitable to the needs of people living with dementia. We saw a bus stop had been painted in one area of the home with a bench and we did see some people use this during our assessment.

Not all people could access the outdoor space due to uneven slabs on the patio area, and the grassed garden was not currently accessible. We did observe some people use the patio area when going outside for a cigarette. This space however was not well kept as there was cigarette debris on the floor. The provider advised us plans were in place to landscape the garden to enable people to have access.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Not all staff had completed core training in accordance with the provider’s expectations to ensure staff were skilled and competent in their role. Training information shared with us by the provider showed some staff had several gaps in their training. For example, a senior staff member had only completed 11% of the training assigned them to complete as part of their role. The provider was taking action to encourage staff to complete this training, and more face-to-face training was being planned. Some staff had not completed training in accordance with the needs of the people who lived in the home including sensory needs and some mental health needs. Staff were not familiar with best practice guidance with supporting people whose needs included learning disability. This meant people were at risk of being supported by staff without the skills to fully meet their needs. [JL1][CW2]

We received mixed feedback from people, relatives and staff about the staffing levels. Some people and relatives told us they had to wait sometimes for staff support. One person said, “At busier times you can be waiting for staff to come, you just have to be patient.” A relative told us, “There seems more staff here today because you are here, I wish it was like this all the time.” A staff member said, “I always feel rushed we have some highly dependent people here that need our support and attention so sometimes people have to wait.” Feedback from other people and relatives indicated staffing levels were satisfactory. Feedback from healthcare professionals indicated occasions where they had to wait for staff support when undertaking routine visits to meet people’s healthcare needs.

A staffing dependency tool was in place, and the management team advised this was kept under review. This tool was based on tasks and meeting people’s core needs. The tool did not take into consideration people’s emotional, and social needs and providing meaningful activities. We observed on both days we visited the home, occasions where staff had to ask people to wait for support as staff were busy supporting other people. This feedback was shared with the manager.

Processes in place ensured staff were recruited safely and necessary checks were completed prior to staff commencing employment. This included reference checks; proof of identity checks

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

On the first day of our visit there was a strong odour in the home. We also found some bedrooms had an odour due to damaged flooring. The provider did take action in response to our feedback to address this. The provider told us action was planned to replace damaged flooring in the home. As detailed previously a refurbishment programme was in place.

A relative told us, “The facilities are not the best, it needs a good clean and redecoration.” We found some areas of the home and some equipment such as the hoist had not always been cleaned appropriately and there were stains and dust evident. This feedback was shared with the manager to address.

The records shared with us showed not all staff had completed infection control training and action was being taken by the provider to address this.

Staff confirmed they had enough Personal Protective Equipment (PPE) available for their use.

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.

People and their relatives told us staff overall ensured they received their medicines as prescribed. One person said, “The staff give me my tablets, they are always on time, and I have never had any problems.” However, due to gaps in records we could not be assured people had their prescribed creams applied when they needed them. We also found several creams had not been dated when they were opened for use, and in some instances the prescribed labels had worn off so we could not be assured who the cream belonged to. We shared this feedback with the manager and provider who had identified some of these shortfalls and was taking action to review the systems in place to improve consistency across the staff team.

We saw people had prescribed creams stored in their bedrooms. However, risk assessments had not always been completed to ensure safe practices were being followed, such as the safe storage of these.

Feedback from people indicated they were not always given the opportunity to self-medicate when this was their preferred option. This feedback was shared with the manager and provider who advised they would undertake the required risk assessments to ensure people could safely manage their own medicines where required.

Staff told us they had received training to administer medicines and records confirmed this. Competency assessments were also completed on staff following this training to check and monitor staff practices.

We saw risk assessments were in place for those people who smoked and used flammable creams. We observed staff supported people to use fire aprons to reduce the risks.