Ryhope Manor 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 inadequate. 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.

The service was in breach of legal regulation in relation to the way medicines and environmental risks were managed.

This service scored 53 (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. They did not listen to concerns about safety and did not investigate or act upon safety concerns. Lessons were not always learnt to continually identify and embed good practice.

During the last assessment there were significant concerns around health and safety, medicines management, staffing, activities and the quality of care. Although some improvements had been made, a number of concerns were still found. This meant the provider had not fully listened to or learnt from the findings of the previous assessment and acted effectively to ensure the home was safe and effective.

Incident records relating to people’s behaviours which challenge lacked detail about what happened before, during and after the event, to support management to identify any potential triggers, identify themes and learn lessons to keep people safe.

Accident and incident records were recorded. The registered manager reviewed these to identify any themes and trends. However, there was no recorded information to demonstrate learnt lessons. The registered manager could explain about lessons learnt and actions taken but acknowledged there was no written record. The registered manager confirmed they would act to address this.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

Senior staff met weekly with the GP, community frailty nurse and pharmacist to discuss people’s health, support and medical needs. A health professional told us, “We have a list of any outstanding actions that we update during our MDT meetings. It includes routine issues and jobs of things that require to be completed for people. We then review at the next MDT meeting. [Deputy manager] guides the staff to follow through on whatever has been prescribed or requested for people.”

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.

People and relatives felt the service was safe and people were protected from abuse. A person told us, “I don’t have any worries and yes, I do feel safe. The staff help me, and they are nice.”

The registered manager maintained a log of safeguarding incidents which included immediate action taken and outcome from the local authority. However, the records would benefit from further detail to inform what happened. The registered manager was going to review this.

Deprivation of Liberty Safeguards (DoLS) had been applied for in a timely way, and any conditions were appropriately added to people’s individual care plans. The registered manager recorded and reviewed them regularly.

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

Risks to people’s individual needs were mostly assessed and managed. However, a small number of risk assessments required updating or implementing to ensure they fully reflected people’s needs. For example, where people were at risk of skin damage or choking.

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

There were several doors found to be unlocked or unlockable during our site visits. These included access to the kitchen, the laundry and 2 stairwells. There were 2 doors unlocked or open, with alarms deactivated, that lead to the outside grounds. This posed a significant risk to people, particularly those with cognitive conditions, as the outside grounds led to a busy road.

The fire risk assessment was not up to date. It was last reviewed in July 2023 and did not contain details of the locked garden gate to the rear of the property. We raised this with the registered manager during the assessment to review.

LOLER (Lifting Operations and Lifting Equipment Regulations) checks had been regularly completed for all mobile lifting equipment in the home. However, the lift and a stairlift was not checked regularly and did not have an up-to-date LOLER check. The provider took immediate action to schedule those checks with an appropriate service.

Asbestos and legionella risk assessments were in place, although some legionella actions lacked evidence of completion.

There had been some improvements to the premises and the grounds since the last assessment and decorators were present in the home throughout the site visits. The provider shared plans for further improvements that were scheduled to be completed within 6 months. These included new flooring in corridors and communal areas and replacement windows and frames in the conservatory.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The registered manager determined staffing levels in line with people’s individual support needs.

People and relatives felt there were enough staff to meet their needs. A relative told us, “The manager always seems busy but there are a lot of staff around.” People said staff came quickly when they pressed their call bells, which we observed during site visits.

Staff were recruited in a safe way. Improvements had been made since the last assessment, and the provider now had an effective recruitment and selection policy and procedure which included all appropriate checks. Relevant checks were carried out in relation to agency staff, to ensure they were trained, qualified and experienced prior to working in the home.

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 home had a COVID outbreak during the first two site visits. Management took appropriate action to mitigate the spread of infection and reported the outbreak to Public Health England. Staff generally followed PPE protocols, though some lapses were observed. For example, staff wearing masks under their chin or nose.

The home was generally clean and tidy, with no odours detected. Domestic staff were visible around the home, cleaning communal areas as well as people’s rooms.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some improvements had been made since the last assessment; however further improvements were needed in the records and guidance for medicines and care planning.

We looked at the medicine care plans for 5 people, some of these were not sufficiently detailed or contained conflicting information. Medicine stock balance sheets were in place for assurance. However, there was a problem with the electronic medicine records system that meant not all medicine administration was recorded accurately. The provider was working with the system provider to address the records issue. We were told medicines that needed to be given at specific times were given correctly, however the electronic record system did not reflect this.

Guidance was available for creams applied by care staff as part of personal care; however, records were not fully completed, and clearer guidance was needed for some people. Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Information on how these should be taken were only available for a few medicines and further person-centred information was needed.

We observed medicine administration to 2 people; staff were respectful, and people were given the time they needed. People’s medicines allergies were recorded accurately.