Raleigh 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. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 used audits, spot checks and quality assurance policies to check practice and identify opportunities to learn and develop the service. Regular supervision, appraisals and team meetings gave staff opportunities to reflect on practice and discuss learning.

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.

People had detailed assessments and care plans, including “This is me” profiles, communication passports, risk assessments, and health action plans that incorporated advice from specialists such as speech and language therapists and dieticians. Hospital passports and AE grab sheets supported safe transfer to hospital, although one person’s grab sheet needed updating to reflect their new DNACPR form and the manager agreed to do this promptly. There was regular liaison with GPs and community professionals; for example, the GP phoned weekly to review one person’s health and there were timely referrals to behaviour support and mobility services when people’s needs changed.

The provider worked with people and healthcare partners 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. The provider shared concerns quickly and appropriately.

Staff and leaders told us there were currently no safeguarding concerns, accidents or incidents, and there was evidence of effective joint working with the local authority in relation to a historic concern, which had been fully investigated. Safeguarding and whistleblowing policies were readily accessible, and included clear contact details for the local authority so staff could raise alerts promptly. Staff described how they would respond to unexplained injuries, prioritising people’s safety.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found staff were appropriately seeking legal authorisation to deprive a person of their liberty where they felt this was required to keep people safe.

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.

Care plans and risk assessments described what was important to each person, how they communicated and how staff should support them to be as independent as possible while keeping them safe. During mealtimes, staff followed specialist guidance to ensure people were protected from the risk of choking and received appropriate nutrition according to their needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Leaders used environmental audits and weekly checklists to monitor the cleanliness, safety and suitability of the environment and took action where issues were identified. For example, a damaged bath panel that could present a risk had already been reported to maintenance, and window restrictors were scheduled to be re‑installed following recent window replacement.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staffing levels were planned according to people’s needs and to ensure there were sufficient staff to support people at the home and to access activities in the community. Safe recruitment checks were in place to ensure suitable staff were employed. New staff completed a structured induction and completion of the Care Certificate where required. Staff received regular training and the registered manager monitored completion to ensure everyone remained up to date.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an infection prevention and control (IPC) policy in place, supported by a named IPC lead who monitored training and worked with staff to maintain a clean environment. Staff received training in infection prevention and control and had their competency assessed as part of induction and ongoing supervision. We observed the home to be visibly clean and hygienic, with no unpleasant odours. During lunchtime observations, staff wore gloves when preparing and serving food, and washed their hands between tasks. Bathrooms and the wet room were equipped with appropriate handwashing facilities and bathing products, and staff discussed the most appropriate cleaning products to use, showing an active focus on infection control.

The provider made sure that medicines were safe and met people’s needs, capacities and preferences.

Medicines were stored securely in a locked cupboard, using blister packs that clearly described each medicine, and staff completed medicine administration records accurately. All staff who administered medicines received training and regular competency checks, and medicines audits were combined with staff competency reviews to monitor safe practice. As‑required medicines such as paracetamol had protocols, stock counts and clear recording to show when and why doses were given.