The Royd

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 changed to 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.

Whilst risk assessments were in place they sometimes lacked sufficient detail and were not always followed, increasing the potential for harm. Environmental safety was also a concern, with significant issues identified around fire safety, rubbish disposal and window restrictors. These shortfalls meant there was an increased risk to people’s safety and wellbeing.

This service scored 62 (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.

The service demonstrated a positive learning culture where incidents were investigated promptly, and lessons shared across the team. When significant events occurred, such as medication errors or falls, the provider’s regional Quality Team reviewed them and produced a lessons-learned document. These were discussed during staff handovers and meetings, and confirmed in meeting minutes we reviewed. Staff told us they were encouraged to stay informed and take responsibility for learning. One staff member said, “I always make the time to read the policies, documents shared and to ensure I keep up to date with my training.”

People and staff were supported to raise concerns about safety and felt confident these would be acted on. One staff member told us, “I feel safe, managers are supportive with any issues or problems.” A relative also said, “They take my concerns seriously and will deal with any concerns I have.”

Accident and incident guidance was in place and clearly stated investigations were essential to understand what went wrong and prevent recurrence. We saw evidence that learning from other services within Lifeways was shared internally, with actions cascaded by the risk manager to management and then to staff. Staff understood when and how to record incidents. Accidents and incidents were initially documented on paper and then entered onto an electronic system by management for monitoring and follow-up actions.

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.

The service had clear processes for assessing new care packages to ensure safety and compatibility. Referrals were reviewed by a dedicated team, and the manager carried out assessments alongside the referral’s assessor. People were invited to visit the home, meet staff and residents before they made a decision to move in. Where risks were identified, these were discussed at a risk panel to decide whether the service could safely meet the person’s needs. People who already resided at the service were encouraged to raise any concerns following an introductory meeting of someone new potentially looking to move into their home.

The service worked closely with healthcare partners to support continuity of care. Staff described a strong relationship with the mental health team, saying they responded quickly when concerns arose, helping prevent hospital admissions. One staff member told us, “We can call them and they come out immediately – it stops the revolving door.” The service also liaised with the GP and shared how they liaised with specialist teams to support a person’s treatment at home when required.

The manager explained that whilst the service aimed to support people back into the community, the service was their home and they would do what was needed to support them to be comfortable in their own home, where they have established relationships and familiarity. Where the service could no longer meet people’s needs, alternative arrangements were explored to ensure safety and continuity.

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.

The service demonstrated a strong commitment to safeguarding. Safeguarding concerns were recorded on an electronic system and escalated appropriately. All staff had completed safeguarding training, with a 100% compliant rate. Staff understood their responsibilities, one staff member told us, “Safeguarding is everyone’s responsibility – we protect vulnerable people and raise concerns to managers if needed.” Most people and relatives told us they felt safe. One person said, “I feel safe at the home, the staff make me feel secure, my personal items are safe and I have never had any issues.” Another added, “I feel it is a safe place to live.” A relative told us, “If I had concerns, I would raise them, but I don’t have any.” We observed the front door was occasionally left open when a resident went outside. Staff reminded the person to close it, as they sometimes forgot. We raised this with the manager, who agreed to consider a more effective solution. A person using the service told us “This made them feel unsafe”, however staff were quick to intervene and reassure them that they were safe.

Processes were in place to protect people from financial abuse. Most people had an appointee, and the home followed robust systems for managing money which included signed records, monthly audits, and receipts checked by head office. Where bank cards were used, people entered their own PINs, and staff did not have access to this information. One person’s money was managed by the home with their consent. Risk assessments and oversight processes were in place.

The provider did not always work well with people to consistently understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and in line with individuals care plans.

People were informed about risks, and staff were generally aware of how to support them, however there were inconsistencies in practice. Risk assessments were in place, however some lacked sufficient detail to ensure risks were fully mitigated. For example, a smoking risk assessment was basic and did not include measures for night-time smoking, despite daily records showing this was an issue. Staff tried to discourage smoking outside at night because it was dark, however this was not reflected in the risk assessment. There were no alternative smoking spaces available. We also found a risk assessment for a person using flammable creams was not always followed by staff, which increased potential harm.

Staff explained they completed a risk screen when someone moved in and involved the person in decisions, even if they made unwise choices, provided they had capacity to make such decisions. Staff said they take time to explain risks and encourage safer options. Positive risk-taking was evident in some cases. For example, staff successfully motivated a person who was fearful of falling, to go outside with support, which staff described as a success that boosted team morale. People’s care plans included foreseeable risks and aimed to use the least restrictive measures to protect rights and dignity. Staff were able to manage distress and emotions in a way that maintained people’s dignity. However, improvements were needed to ensure all risk assessments are detailed and consistently followed.

The environment was not consistently safe or well maintained. Significant risks were identified that could compromise people’s safety and wellbeing.

During the inspection, we found serious concerns relating to fire safety, rubbish disposal, window restrictors, and the overall environment.

Fire safety information in the activities room was incomplete and not clearly displayed, increasing the risk that people may not know how to respond or where to assemble in the event of a fire. Two fire doors did not close effectively, compromising the integrity of the fire door. Rubbish and debris were observed at the bottom of an external fire exit which partially obstructed a designated escape route. Care plans did not always contain sufficient evacuation details in the event of an emergency. This lack of readily available information could delay appropriate evacuation procedures.One cellar was heavily cluttered with paper and unused items, creating a fire hazard due to the increased risk of rapid fire spread from accumulated combustible materials.

A Biffa bin was overflowing, with a mattress behind it and gloves scattered on the ground. A glass panel was found in one of the gardens and further rubbish was located outside the fire exit of the kitchen. creating an environmental hazard and potentially obstructing safe access or evacuation routes in the event of an emergency. The presence of waste increased fire risk and poses a potential health and safety concern for people living and working at the service.

Some windows, including those in the stairwell and some bedrooms - could be opened fully and did not have the required window restrictors in place. This created a significant safety risk, as unrestricted windows at height increase the likelihood of falls, particularly for people who may be vulnerable or lack awareness of the danger.

We found loose fixtures, visible water damage, and unresolved maintenance issues across communal areas. The kitchen also showed signs of poor upkeep. Several bedrooms and bathrooms were similarly poorly maintained, with worn furnishings and damaged fittings that made effective cleaning difficult. Overall, the standard of the environment did not support people’s dignity, comfort, or safety. One person said, “I think they could buy new carpets and redecorate the communal areas”. These deficiencies created an environment which would be difficult to clean effectively and may compromise infection control standards. The overall deterioration of fixtures and furnishings presented a risk to people’s dignity and wellbeing, as it did not provide a safe, comfortable, or homely setting.

Following an immediate action request, the provider took action to resolve some of these concerns. Restrictors were fitted to all but one window, which was in a vacant room, fire doors were repaired or replaced, and the cellar was emptied. The rubbish outside the property was collected, and all but one glass panel had been removed.

Despite these concerns the service tested their fire alarm system regularly, along with completing fire drills to ensure systems were in good order and staff knew how to respond in the event of a fire. People living at the service and relatives told us they felt the environment was clean and comfortable. One relative said, “The sitting room, dining area, and my loved one’s room are always tidy and clean.” A person living at the service told us, “The furniture is comfortable, and my room is kept nice and clean.”

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.

Robust recruitment practices were mostly in place. We saw evidence of identity checks, right-to-work documentation and Disclosure and Barring Service (DBS) checks. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. While there were some gaps in historical employment records for long-serving staff, recent applicants had complete employment histories and verified references.

Staff received induction training which included shadow shifts, mandatory modules such as safeguarding, mental health recovery, and infection control. Training records showed high compliance in key areas such as medication, fire safety and safeguarding. Staff were clear about their responsibilities during the event of a fire. One staff member explained, “When the alarm goes off, doors shut, and we know where we need to be and who needs to be evacuated... Night staff are trained too.” Additional training included basic life support, capacity and decision-making, food safety, health and safety, and manual handling. However, equality and diversity training and dementia training required some improvement as several staff had not completed these modules.

Team meetings were held frequently, with options for night staff to join online. Managers operated an open-door policy and provided on-call support for emergencies. Competency checks, spot checks and supervisions were carried out regularly. Staff confirmed these took place and described practice observations, spot checks and medication competency assessments. Managers monitored compliance through internal reminders and training spreadsheets. One staff member told us, “We have supervisions every couple of months, we talk about the residents, the company and what I need for my development”.

Managers were proactive in supporting staff development and adapted training to meet people’s changing needs. They discussed mental health and recovery approaches in team meetings and supervisions. Staff described the environment as supportive and approachable. One staff member said, “It’s a very good working environment. If you’re unwell, managers check in and make sure you’re okay.” Rotas showed regular staffing patterns and a regular number of staff in each day. People using the service generally felt there were enough staff, although one person commented, “I don’t think there are enough staff… but they do come quickly if I need them.”

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

Several hand sanitiser stations were not working in key areas such as the kitchen and living room. In one house, mops were stored with heads facing down, which is not in line with infection control best practice, and empty bedrooms were cluttered and not maintained when empty. Some staff wore very long painted nails, which may increase the risk of infection when delivering personal care and was against providers IPC policy. The general condition of the environment, including peeling paint and old fittings such as a dirty fluorescent light, meant it was difficult to clean effectively and did not support good infection control standards.

Despite these concerns, staff followed national guidance when using personal protective equipment (PPE), and we observed appropriate handwashing. Staff understood food safety requirements, and food was correctly labelled and stored. Laundry facilities were available, and people were supported to do their own laundry where appropriate. Infection control training had been completed, and audits were carried out twice a year which included mattress checks with action plans. The service had clear policies in place and described the steps they would take in an outbreak, such as isolating affected areas, using red bags for soiled laundry, and ensuring PPE was available. Relatives told us the building was usually clean and tidy, with one saying, “The home is always very clean.”

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

Medication management was generally safe and well understood by staff. Care plans included clear instructions on what to do if someone refused medication and how to respond to signs of mental health re-lapse. Staff were aware of the “Five R’s” of medication administration with one staff member explaining “When administering medication, we ensure we have the right person, the right drug, the right dose, the right route and the right time”. Whilst staff were mindful of timings, people who used the service also reminded them as it neared the time for them to have their medication. One staff member told us, “Residents remind you when it’s close to medication time because it helps them feel better.” Processes for ordering, checking and returning medication were in place. Staff monitored medication room temperatures twice daily and checked fridge temperatures to ensure safe storage. People and relatives told us they felt the handling of medication was good. One relative said, “Medication seems to be managed well” and a person using the service told us, “I’ve never had any issues with medication being late or running out.”

However, some areas required improvement. Thickener was initially left unsecured in the kitchen as staff seemed unaware it should be locked away. Staff were quick to rectify this and ensured that the thickener was secured immediately and that their colleagues were informed. PRN protocols (for as needed medication) were in place for most medicines, but one protocol was missing for a recently added medication. The example protocol provided had not been reviewed for over 12 months. Despite this, staff were able to describe that medication reviews were carried out quarterly with input from the pharmacy, doctors and the mental health team.