Rathgar 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.

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.

This service scored 56 (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 systems and processes in place to report accidents and incidents, including a monthly review of themes and trends.

Where lessons learned had been identified, the provider recorded these in a lessons learned log. For example, a medicines error in April 2026 was recorded, including evidence of learning and reflection.

The manager and staff were able to articulate the actions taken in response to incidents, however, we found some incident records required further detail to be assured that appropriate governance processes had been followed to investigate incidents and mitigate risk. For example, the provider’s review of five incidents did not identify a person did not have adequate care plans and risk mitigation in place in relation to falls.

The provider had systems, processes and policies in place to support safe systems, pathways and transitions. For example, we saw evidence that initial assessments were completed prior to people moving into the service, and there was an emergency pack to support people’s admission to hospital.

We received positive feedback from relatives in relation to transitions. For example, a relative told us, “The move was smooth and staff helped mum to move things to her room. We had looked at about four homes, but this one came out on top because they were focussed on [name of person] unlike the others.”

The service accepted people from the local authority on a discharge to assess pathway. This type of pathway supports people on a temporary basis to be cared for by the provider while assessing their needs to see if they require a 24-hour care provision. Although we found initial assessments had been carried out, we identified two people on this pathway who had lived at the service for several weeks without adequate care records.

Staff knew people, however, the lack of care records meant people were at risk of not consistently receiving the care they required or changes to their needs being recognised and responded to. We were not assured by the provider’s governance arrangements in relation to safe systems, pathways and transitions.

The provider assured us by the end of the assessment that adequate care records had been completed and there had been learning in relation to this finding.

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 had safeguarding policies and procedures, supported by systems and processes to record safeguarding concerns, and the provider carried out reviews of safeguarding themes and trends.

People and relatives told us they felt their loved one was safe living at Rathgar. For example, a person told us, “Yes. I feel safe. The people I live with are part of my family.” A relative also told us, “I feel that my [name of person] is totally safe at Rathgar.”

Deprivation of Liberty Safeguards DoLS applications had been made where people lacked capacity to consent to living at the care home.

The provider did not always work with people to understand and manage risks.

Staff had an understanding of people’s risks and we observed that staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider carried out individual assessments in relation to risk. We found not all assessment were person-centred and some did not contain guidance that was appropriate to the specific risks identified. For example, an anti-coagulation risk assessment contained generic guidance about anti-coagulation medicines a person was not prescribed.

We found the provider had not established risk mitigation plans for all known risks for two people living at the service who had lived at the service for several weeks. This meant staff did not have adequate guidance to support people to manage their risks.

The provider had told us by the end of the assessment that adequate risk mitigation plans were in place and shared their policy to assure us of the process that would be followed for future admissions.

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.

The provider had health and safety policies, and all statutory compliance checks had been carried out by the provider or approved contractors. The provider told us that the building required some updating and shared their maintenance development plan. For example, the laundry floor required replacement.

We found a ramp at an exit to the rear of the building was not fit for purpose and posed a risk to people exiting the building. Although the ramp had been included in the maintenance development plan, the provider had not taken effective action to mitigate the potential risk to people in a timely way. The provider took action during the assessment to replace the ramp.

We found the number of personal emergency evacuation plans (PEEPs) did not match the number of people currently living at the home, and other PEEPs required further review to ensure these reflected people’s individual needs.

We observed an unplanned fire alarm during our assessment. Our observations showed this was being well co-ordinated by the staff member leading the shift. However, there were aspects of the evacuation that did not follow the provider’s evacuation procedure suggesting staff did not consistently understand the procedure.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

The provider had a range of mandatory and specific training to meet people’s needs, including competency checks and induction to the service.

Feedback from people, relatives and staff indicated there were enough staff on shift to meet people’s needs. This was confirmed by rotas and our observations of staff practice and interactions. A person told us, “There is always someone to help - the come when I call them.” A relative also told us, “They have enough staff. They come very quickly if the call bell is pressed.”

The provider had recruitment systems and processes. We found the provider had not viewed the original criminal records certificate for a staff member with a DBS (Disclosure and Barring Service) check on the online update service. We also found one employment reference for a staff member required further validation, as we were not assured the reference had been provided by a person authorised to give an employment reference.

The provider told us they had taken action to address these concerns and the required checks were in place by the end of the assessment. We were assured that the provider was taking action to address our findings.

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.

The provider had infection prevention and control policies.

The provider had a cleaning schedule in place, and we found the standard of cleanliness in the home reflected how often records indicated the service was being cleaned. A relative told us, “Whenever I’ve visited, the premises and [name of person] room are always clean.”

We found that safe food practices were in place; for example, all open food had been labelled with the date it was opened.

Staff had received relevant training and had access to an adequate supply of PPE.

The provider had medicines policies and procedures and there were systems in place to ensure that people received their medicines as prescribed.

Medicines records we reviewed found people had received the medicines they were prescribed.

Staff training records demonstrated that staff responsible for administering medicines had completed appropriate medicines training and competencies relevant to their roles.

We found that ‘as required’ (PRN) medicines protocols did not always contain adequate guidance to support staff to administer medicines consistently. For example, for people prescribed medicines for constipation, there was insufficient guidance on when to administer the medicine and when to escalate concerns to a health care practitioner.

We did not find the need to improve PRN records had impacted on people because staff had good knowledge of people’s needs. However, there was a risk that people may not receive their medicines in a consistent way without adequate guidance for staff.

We were assured by the provider they were taking action to improve the quality of information in PRN protocols by the end of the assessment.