Redroof House Supported Living

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

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always analyse concerns about safety and did not always investigate possible themes. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents were recorded; however, the service did not evidence lessons learnt, or action taken as a result. This meant they were not proactive in their approach to learning. The provider told us they would review the accident and incident forms to include information on lessons learnt and resulting action. However, staff told us they knew how to report concerns.

The service did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including for people’s care needs in the service and when people moved between different services.

People had information on their individual health needs that could be shared with health and social care professionals, for example when attending hospital. However, this information was not always accurate to ensure the smooth transitions between medical services

People’s care records were not audited to ensure accuracy. New information received had been added to care records but the absence of auditing meant the provider could not be assured this was always accurate.

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.

Safeguarding procedures were in place to ensure people were protected from avoidable harm. Staff told us they had training in safeguarding. Staff were aware of their responsibility to safeguard people from abuse or neglect. Staff told us the types of abuse, the signs of abuse and apply this to everyday practice. A member of staff said, “I would record and report [an unexplained bruise]. If I was not happy with the action taken by the managers, I would call CQC or safeguarding at the council.”

A social care professional told us, “Based on my observations Redroof appear committed to keeping individuals they support safe.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. Where people were subject to restrictions for their own safety, the provider had worked with the local authority to apply for DoLS authorisations.

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

The provider’s risk assessment policy concentrated on organisational risks and did not set out procedures for managing people’s risk assessments. Risk assessments were not always accurate and did not always signpost to guidance accurately. For example, one risk assessment referenced guidance from a health care professional, a copy of this was not available. There was correct guidance this was in the person’s health action plan. However, this was not referenced in the risk assessment. This meant staff did not always have access to information about how to support people safely. We raised this with the registered manager, who took action to address the shortfall.

We observed staff supporting people safely when moving around the service. One person told us, “I feel safe and like living here [the service].” People were encouraged to be taking positive risks, such as travelling independently to get to activities.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety checks had been completed, including fire safety assessments and fire drills. A system was in place to ensure checks, including gas safety, electrical safety and emergency lighting, had been completed. Documentation was in place to confirm the service complied with relevant legislation. A plan was in place to redecorate the service, which included completing necessary maintenance work and addressing environmental risks.

The service did not always evidence there were enough qualified, skilled and experienced staff. They did not have systems in place so they could check that safe care that met people’s individual needs was always in place.

A member of staff told us, “The registered manager and senior staff dip in quite often to provide additional support to people and also staff provide additional hours of support sometimes.” We observed this happening during the assessment, but this support was not documented. This meant the care that was provided was not accurately recorded and the provider could not be assured the correct commissioned care hours were reflected in practice.

This also meant the provider could not be assured that people received effective staffing at a level that fully utilised the support hours available to them.

Staff were skilled and had received sufficient training to support them with meeting people’s needs and were being supported to develop their skills further. A member of staff told us, “I am doing additional training outside work and they [the service], is supporting me to do this.”

Staff told us they felt supported and received supervision. One member of staff told us, “In our supervisions they talk about our progress and any issues. They give me suggestions to improve my skills and set targets for the next supervision.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were protected from avoidable harm as there were safe infection prevention and control measures within the service. We observed the service to be clean and tidy and there was work on-going around the redecoration of the service. Cleaning duties were checked and recorded as completed during handovers between staff shifts. We observed good hygiene procedures. Personal protective equipment was observed to be worn correctly by staff.

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

People did not always receive their medicines as prescribed as the provider had not always followed their medicines policy. For example, the medication policy stated it was staff’s responsibility to ‘note any out-dated medicines and arrange for these to be returned to the pharmacy’. We were told that unused medication was disposed of in general waste in the service. Similarly, the policy stated it was the organisations responsibility in ‘maintaining comprehensive and accurate records of all medicines administered to the service user.’ There were no recorded balances of medication to be able to check that these were correct. This meant medication systems did not provide management oversight so that that it could be assured that people had their medication as prescribed.

The procedure in place around people self-medicating and staff’s role in supporting this had not been followed. There was no documentation in place around how the decision for people to self-medicate had been made and the level of support people needed to be as independent as possible, as described in the policy.

However, staff had received training in supporting people with their medicines, and a member of staff told us how they administered an individual medication in line with good practice.