Roberttown Care Home Limited

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 regulation in relation to safe care and treatment.

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not consistently investigate or report safety events.

Risks were not always identified or managed effectively and this was a continued concern from the last assessment. There was some basic management oversight of accidents, incidents, and falls, but this was not always robust or with sufficient investigation or analysis. Some root cause analyses were completed but there were missed opportunities to identify and disseminate learning from these.

One relative told us they did not feel there was any learning identified in relation to their relative’s repeated falls and felt this could be improved.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not sufficiently manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The manager told us they took responsibility for ensuring pre-admission assessments were completed. Pre-admission assessments were not always fully in place and not always completed in detail. For example, 3 out of 4 pre-admission assessments we reviewed lacked critical information. One person was at high risk of falls, yet their falls assessment was not completed until shortly after their admission, when they sustained a falls injury.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff understood how to identify and share concerns in relation to safeguarding. The manager knew to report safeguarding referrals to the local authority safeguarding team. However, some safeguarding risks were not clearly identified or shared with staff. One person had known safeguarding concerns but there was no plan in place to ensure their safety. Another person had known risks around their behaviour, which presented a safeguarding risk to others, yet there was no risk assessment at the time of inspection. This meant there was a continued risk to people's safety and wellbeing.

Some people told us they did not feel safeguarded against possible abuse or neglect and we shared concerns raised by 3 people, to the attention of the management team. This was promptly acted upon and appropriate safeguarding measures taken to ensure people’s safety.

We found the provider had a system in place to monitor and review the use of Deprivation of Liberty Safeguards (DoLS), including oversight of conditions attached to authorisations. Where restrictive practices were in use, such as falls sensor mats, appropriate mental capacity assessments and best interest decisions had been completed in accordance with the Mental Capacity Act.

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.

Some risk assessments were not sufficiently in place detailed or accurate and did not provide staff with enough information on how to manage and mitigate identified risks. Some of the risk assessments in place had contradictory information such as both ‘high’ and ‘low’ risk stated. Falls, accidents, incidents, and behaviour monitoring records were not thoroughly reviewed to identify triggers or ways to reduce occurrences.

Records showed that some people had experienced distressed behaviours. However, the provider did not ensure care plans were in place to support people. It was not clear what strategies staff were using to reduce people’s distress or the impact on others. The manager described risks around one person’s behaviour towards others, yet there was no care plan or risk assessment in place for this. These were implemented following our inspection visits.

Since the last assessment, the provider had made improvements around management of weight loss. Records showedpeople were being weighed on a regular basis, withappropriate conversationswith GPs and dieticianinput, along with fortifiedsupplementswhere needed.Care plans and records however, did not identify if supplements were needed or given.

Following the last assessment, the provider made improvements around falls risks. Where some people were at risk of falls, staff reminded them to use their walking aids. People told us staff knew how to support them with any risks.

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.

Regular checks of premises and equipment were largely in place and up to date. Some aspects of the environment showed areas still in need of repair or refurbishment, particularly in some corridor and communal areas, such as worn carpets and detached radiator covers. The provider had a refurbishment plan in place with dates for completion which was still work in progress at the time of the assessment. People’s bedrooms contained their individual personal belongings and there was suitable signage to communal areas and bedrooms to help people with finding their way round the home.

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. Staff worked together well to provide safe care that met people’s individual needs.

We received mixed feedback about whether the service had sufficient staff deployed to meet people’s needs. Some people told us they had to wait a long time, especially at night for staff to attend to them. Some staff told us staffing levels were not always sufficient to make sure everyone’s needs were met promptly. One relative said, “Some of the carers you cannot fault but there are not enough staff about, particularly at the weekend.”

The provider had significantly reduced the use of agency staff and the service was staffed with regular permanent staff. The manager told us they had reviewed the staffing rotas and made adjustments to ensure the right skill mix was on each shift.

The provider’s training matrix showed staff had completed training and their competencies had been assessed. Staff rotas showed there were some shifts which did not include staff trained in first aid. Staff supervision and appraisal systems were in place, although there had been a delay to the supervision schedule for 2026.

We reviewed 3 recruitment files and found that pre-employment checks had been completed in accordance with safe recruitment practices, including identity verification, references, and Disclosure and Barring Service (DBS) checks.

The provider did not always robustly assess and manage the risk of infection. They did not always detect and control the risk of infection spreading. The provider shared concerns with appropriate agencies promptly.

There were specific areas in need of more robust attention to cleanliness, such as one person’s nebuliser mask, and some bathroom and bin areas.

The premises were mostly clean throughout and free from malodours, and there were daily schedules for cleaning. Staff followed suitable hygiene practice and hand hygiene facilities were available and appropriately stocked.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had addressed some of the concerns from the last inspection, however there were still a number of continued weaknesses resulting in continuing unsafe systems and processes for managing medicines.

Issues around lack of medicine stock and recording of allergies had been rectified since the last assessment. However, people were not always given their medicines safely. Staff did not always demonstrate safe practice around administration, which the provider addressed immediately. For medicines given ‘as required’, protocols were not personalised or detailed enough for staff to make fully informed decisions, and there were limited checks on medicine effectiveness. People with medicines patches did not have these applied correctly as per manufacturer guidance. We found discrepancies in stocks of tablets counted for one person, against the recorded number on the provider’s system, as well as some concerns around disposal and recording.

The provider did not have robust practice in relation to supporting people who managed their own medicine, or for those people on covert (disguised in food) medicine. For example, one person taking their own medicine was being supported by a visitor to do so, and staff contacted one person’s relative to come in and support them with giving their medicine. Where one person needed rescue medication for a severe allergy, staff were unclear where this was located. The provider took action to improve this during the assessment.

Checks were made weekly and monthly by managers to ensure medicines were managed safely. However, the checks had not identified the concerns we found about medicines and when concerns were identified by the provider’s own audits they had not always been resolved.

We found no evidence that people were harmed at the time of the assessment. However, people were placed at continued risk of harm by not managing medicines safely.