Romney House

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 Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 38 (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 based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Records did not demonstrate effective systems to minimise the risk of a reoccurrence following an accident or incident. For example, the cause of a person’s bruising to their leg was described as frailty and prescribed anticoagulants. Whilst a GP confirmed this, there was no further investigation to identify any other potential causes. This did not enable effective learning or to minimise a further occurrence.

Accidents and incidents were recorded on the person’s individual care records but there was no overview. This did not enable any patterns or trends to be identified and addressed to enhance safety.

Leaders told us they spoke to staff about any safety events or required changes in practice. However, these discussions were not documented, and there was a risk not all staff would be informed.

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

Leaders told us they had developed established relationships with various health and social care professionals. They said the GP and community nurses routinely visited and could be called upon as requested in addition. A health and care professional confirmed this. They were positive about the care delivered and said staff always contacted them appropriately if medical expertise was required. They said staff followed any instructions they gave and would contact them again if needed.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

People gave us variable feedback about feeling safe in the home. Two people told us some of the staff particularly at night were abrupt and did not always deliver the care they requested. One person said their call bell was not always answered, which meant on one occasion, they went to toilet unsupported. This increased the risk of them falling and sustaining an injury. Two members of staff told us some staff who worked at night turned the call bells off, which is why they were not answered. They said they had raised this with leaders. We discussed night-time care with leaders, and they were concerned about our feedback. They said they were not aware of the call bells being turned off but would address this with staff and undertake further investigation and monitoring.

Records demonstrated not all staff had received up to date refresher training in safeguarding. Leaders told us they were aware of this and were in the process of arranging face to face training for the whole team. Staff told us they would tell leaders if they had any safeguarding concerns.

However, other people told us they felt safe. Specific comments were, “I do feel safe. It is all locked up welI. I’m not allowed to let people in at the front door” and “I feel completely safe and it’s lovely to feel that.” Staff told us they would report any concerns about safety to leaders.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Leaders were able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications and urgent authorisations in a timely manner.

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

Risks people faced had not always been regularly identified, assessed or mitigated. This included the risks of choking, pressure damage and malnutrition. For example, one person had a soft diet due to ill-fitting dentures, but their risk of choking had not been assessed. Their eating and drinking care plan had not been reviewed since March 2025 so there was a risk the information was not up to date. The information did not provide staff with a detailed account of the interventions needed to ensure the person’s safety whilst eating. There was an instruction to monitor the person’s weight monthly due to weight loss, but this was not completed. This did not enable adequate control measures to be implemented if needed.

In February 2025, another person was identified to be at risk of developing pressure sores. The risk had not been further reviewed, which did not ensure it was accurate or that adequate interventions were being implemented. The measures to ensure healthy skin were stated as applying topical creams, and visual checks by the community nurses. However, this was insufficient to safely manage the level of risk identified as important measures such as repositioning, equipment and staff checking vulnerable areas had not been identified. The manual handling assessment stated a hoist was required to assist the person with their mobility, yet staff told us they used a slide sheet. They said this was due to the person’s changing needs, but the risk assessment had not been updated. The person had other risk assessments, but these were dated 2024 and no longer relevant due to being out of date.

However, people told us they were supported with risks such as falling. One person told us, “The girls make sure I am ok because they walk with me to the dining room.” Another person said they had the required equipment to help them with their mobility. A relative confirmed this. They said, “[Family member] has a walker but staff are starting to help them with a wheelchair. They have identified they need more help now.”

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.

There were aspects of the building which were not safe. For example, not all hot surfaces such as radiators and pipe work had been covered, and windows were not fitted with restrictors. This meant people were at risk of burning themselves if they fell against the hot surfaces or falling from height. Monitoring records showed the hot water from some hand washbasins was above the Health and Safety Executive’s recommended safe temperature of 43 degrees Celsius. Action to minimise the temperature of the water had not been taken.

Records demonstrated an external company had tested the environment for the risk of legionella. Their report identified recommendations to ensure safety, but leaders could not confirm these had been actioned. They told us senior leaders held the responsibility for the environment, so presumed all was ‘in hand’. Leaders told us they would confirm this with senior leaders, and ensure any necessary action was taken.

A gate at the top of a stairwell had been cable tied, to minimise the risk of a person falling down the stairs. However, the stairs were an identified fire escape. This meant people could not exit the area safely in the event of a fire. We brought this to the attention of leaders, and the tie was immediately removed. Leaders then offered the person an alternative room away from the stairs, to enhance their safety.

The door to the laundry was propped open and the door to the staff cloak room was not locked. This gave people access to hazardous substances, such as cleaning detergent. Leaders told us the locks on the doors did not work properly and needed to be replaced. They said this work was being addressed, and the new locks were to be fitted. They said they would talk to the maintenance person about this.

Staff and leaders told us about a blockage in the laundry room before Christmas, and how it had caused rats to enter the area. Specialist services had been called to address this, and humane traps remained in situ. However, holes in the walls in the toilets next to the laundry had not been filled in. This did not minimise the risk of the rats re-entering the building. Leaders told us there had not been a further infestation but would ensure this work was undertaken.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Safe recruitment practice was not always followed. For example, complete employment histories were not always identified within application forms. Any gaps in employment had not been explained or verified. This did not clearly evidence the applicant’s fitness or suitability for their role.

People told us there were not always enough staff to support them effectively. One person told us, “There are not enough staff in the afternoon, around tea-time. If you need the toilet, there is not enough.” Another person said, “When I see the carers I try to keep them, but they are so busy, bells driving you crazy in the morning. They can’t spend too much time with you.”

Staff told us having 2 staff deployed in the afternoon and evening was a challenge due to the level of people’s needs. They said there were people who needed 2 staff to assist them with their personal care, which meant others were unsupported at these times. One staff member said staffing impacted on care because people could not have a bath or shower, when they wanted one. Another staff member said it was upsetting as the level of care they could provide within existing staffing levels was limited.

Leaders told us they regularly reviewed staffing numbers but did not have a formal process to assess how many staff were required. They said they had recently identified teatime was particularly busy, so had recruited staff into hostess type roles to support the care staff. Leaders told us they thought this had helped but would undertake a further review.

Staff told us they had not had recent training in certain subjects. Records confirmed this, including first aid, health and safety, mental capacity and moving people safely. Leaders told us this was being addressed as face-to-face training sessions were being arranged.

Leaders were very much part of the working rota and undertook any shifts which could not be covered. They said in addition, they supported people with their personal care and administered medicines if the care staff appeared busy. The service did not use agency staff to ensure people received consistency of care. One member of staff said this worked well. They told us “People pick up if we are short staffed, but we tell them we can handle it. We just get on with things so there’s no impact.”

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

The environment was generally clean although there were splash marks over the legs of the dining room chairs and some walls, and peeling paint in a bathroom. The kitchen had food debris over the surfaces, and some jugs and cups were stained and not clean. There was mould on the shelves which housed food stocks, and the refrigerator was dirty. Some of these areas had been identified in recent audits, and after the inspection, a deep clean of the kitchen was undertaken.

There were bars of soap and communal toiletries, such as moisturising cream and talcum powder in the bathrooms. These were a risk of cross infection if used by multiple people. Leaders told us they believed staff had forgotten to take the items back to people’s rooms but would ensure they were removed.

People were complimentary about the cleanliness of the home. Specific comments included, “Always nice and clean everywhere” and “They are great at cleaning although Sunday is not so good.”

Staff had access to personal protective equipment such as gloves and aprons. We observed this was worn appropriately when handling food. Monthly audits of infection prevention and control were undertaken. The information identified housekeeping staff, and the maintenance person were informed of any shortfalls so they could be addressed.

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.

Staff had not always signed the medicine administration record (MAR) to show they had administered a person’s medicine. This did not ensure the medicines were taken as prescribed or enable the effectiveness of the medicine to be assessed. One person was prescribed a pain-relieving patch that was to be applied every 7 days. However, on 1 occasion it had been applied after 6 days, and on another it was 14 days. These errors increased the risk of the person’s pain not being managed effectively.

Guidance was not available for all medicines to be taken ‘as required’ or those prescribed with a variable dose. This did not ensure consistency or maximise the medicine’s effectiveness. Staff had not documented the variable dose which had been administered, which did not enable effective monitoring. Gels, lotions and topical creams had not always been dated when opened. This did not ensure they were safe to use.

Staff had not always countersigned handwritten medicine instructions in line with the National Institute for Health and Care Excellence (NICE). This did not ensure the information had been transcribed effectively, which increased the risk of error.

Records demonstrated and staff confirmed, not all staff who administered people’s medicines had received up to date training or had their competency assessed. This increased the risk of error. Leaders told us they were in the process of arranging training for those who needed it.

Before the inspection, we received a concern about leaving medicines with people unattended and ‘potting medicines up’ so they could be given later. This is known as double dispensing and is not safe practice. One staff member told us certain staff did this, to help when it got busy. However, we did not observe this practice, and people were happy with the administration of their medicines. Comments included, “They will bring me my tablets, and I take them there and then. I know what they are for” and “They do make sure I have taken them.”

Assessments had identified the risks of flammable emollients and medicines were orderly and securely stored.