Rhodsac 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.

The service was in breach of legal regulations in relation to safe care and treatment and safeguarding people from abuse.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

The provider had not always ensured staff followed safeguarding policies and procedures. This meant incidents had not always been investigated. Nor had steps been taken to mitigate future risk. Not all incidents had been reported to the local authority safeguarding team as required. Following the inspection the provider ensured the safeguarding incidents identified were reported to the local authority.

People living at the service told us they felt safe and comfortable with the staff who supported them. One person said, “I do like the staff they are nice people; all the staff are good.”

Staff told us they had received training in safeguarding adults and knew where the safeguarding policy was. They were able to explain how they would report any safeguarding concerns.

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

Staff did not have clear guidance on how to support people safely and people were not always supported to mitigate known risks. For example, 1 person living with diabetes did not have their diabetes monitored or managed safely. Records of blood glucose level checks and insulin administration indicated the person’s blood glucose levels were outside the identified safe range on several occasions. There was no record to show this was managed as directed in the person’s care plan. Another person’s care plan stated their blood pressure should be regularly monitored, there was no record of this.

People were not always supported to mitigate known risks. The front door was found to be unlocked during the inspection. Staff initially provided inconsistent information about whether the door should be locked. Assessments and care plans did not include consistent information about this. Senior staff later confirmed that due to the needs of people living in the service the door should be locked at all times. There was a risk people living in the service who required staff support when out in the community would leave the service without staff being aware.

Risks to people were not always adequately assessed. Care plans and risk assessments did not always contain current, detailed information about people’s needs in relation to falls and health needs. For example, 2 people with a known diagnosis of epilepsy had no care plan in place for this health condition.

The failure to assess and support people to manage known risks in their lives placed them at risk of not receiving safe care. Following the inspection the provider undertook a review of people’s care documentation to ensure people were receiving the care they required, and all areas of people’s needs were assessed.

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

We found concerns with the safety of the home environment that placed people at risk of harm.

Appropriate fire safety measures were not in place. The actions required by the fire risk assessment had not been completed in the required timeframe and fire drills were not implemented effectively. Fire drills were not carried out under nighttime conditions, which meant the provider could not be assured staff working overnight would be able to respond effectively in the event of a fire.

Appropriate water safety measures were not in place. The hot water temperatures recorded for the months of January, February, March, April, May and June 2025 demonstrated that water coming from taps in hand basins, showers and baths, all of which were accessible to people living in the home, was hotter than 44 degrees Celsius. This exceeded the maximum safe temperatures stipulated in the Health and Safety Executive guidance, ‘Managing the risk from hot water and surfaces in health and social care’. People were at risk of scalding.

Risks associated with Legionella bacteria in water were not effectively managed. No action plan had been implemented to address the concerns identified by the Legionella risk assessment.

Water temperature testing to mitigate the risk of Legionella was not being safely implemented. The hot and cold-water temperatures recorded for the months of January, February, March, April, May and June 2025 were not within the parameters of safe water temperature identified by the Health and Safety Executive as the safe temperature for water distribution in care homes. People were at risk of illnesses that are associated with the risk of exposure to Legionella bacterium.

Radiators in the home had not been designed or covered to ensure they did not heat to a temperature above 43 degrees Celsius stipulated in the Health and Safety Executive Guidance, Managing the risk from hot water and surfaces in health and social care’. No risk assessments were in place to identify and mitigate the risk this may pose to service users.

Some areas of the home were not maintained to a safe standard The paving slabs outside the back door were loose and wobbled when stepped upon, the loose paving slabs posed a falls risk to people living in the home, some of whom were known to be at high risk of falls.

The provider acknowledged the findings of the inspection in relation to environmental safety and began to implement the actions required to make improvements.

Staff were not always recruited safely. We reviewed staff recruitment records and found gaps and inconsistencies in information that was required to ensure safe recruitment. For example, files reviewed did not contain a full employment history or record of interview. The provider had not followed their own policies and procedures in relation to Disclosure and Barring Service checks (The Disclosure and Barring Service helps employers make safer recruitment decisions by processing criminal record checks and preventing unsuitable people from working with vulnerable people). Staff were required to complete annual self-declaration forms, but these had not been completed in line with the policy.

Staff had received the training required to ensure they were able to effectively meet the needs of the people they supported. Staff told us they received training that equipped them to carry out their role. Training records demonstrated that staff had received suitable training in all the areas required for their role. For example, training in learning disabilities and autism.

People told us there were enough staff, but they were not always deployed effectively to ensure people were supported to engage in activities. One person’s relative told us, “I think there’s the right number of staff, it’s just getting them to encourage [person’s name] to do things.”

Rotas showed consistent staffing levels and during the inspection we observed there were sufficient staff on duty to ensure people received safe support.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

People’s medicines were not always stored safely. We saw that 1 person’s medicine had been stored in another person’s medicines cupboard. The lock on the medicines fridge which contained insulin was broken and the fridge could not be locked. Creams that had been opened were not consistently labelled with an opening date; there was a risk they would continue to be used beyond the time period advised by the manufacturer.

Medicines records contained conflicting information. For example, people’s medicines profiles listed medicines that were not recorded on their medicines administration record charts.

Not all staff had received an assessment of their competency to administer medicines. During the inspection we observed 1 member of staff administering people’s medicines, there was no record that their competency had been assessed. Records showed all staff had received training in medicines administration.

Inconsistent medicines management placed people at increased risk of medicines errors and harm.