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We are carrying out a review of quality at Russell Court. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 12 November 2020

During an inspection looking at part of the service

About the service

Russell Court is a residential care home providing personal and nursing care up to 42 people. As part of the local area’s response to the COVID-19 pandemic, the service had agreed with a local hospital to reserve 21 of the care home beds for people recently discharged from hospital. People went into isolation in their rooms on arrival to the home, due to risks associated with COVID-19. Some people were recovering from COVID-19 and following a hospital stay.

There was a quick turnaround of people staying at the home, with some people staying for a short period of a number of days or weeks. On the first day of our inspection, the service was supporting 23 people and on the second day of our inspection six days later, the service was supporting 30 people. Two people lived at the home on a longer-term basis.

People were accommodated in one building that had been adapted to provide designated areas for people with and without COVID-19, to help reduce the spread of infection. People who joined the service with a positive COVID-19 test were cared for in a separate wing which was designated for people with COVID-19 to reside in. There were additional wings and areas of the home designated to care for people who did not have COVID-19.

People’s experience of using this service and what we found

We identified a breach in relation to safe care and treatment because people’s risks were poorly assessed and we found widespread, significant concerns as to how the service managed people’s medicines and the risks associated with COVID-19. Incidents were not learned from to help improve the safety of the service. Though we saw staff were aware of safeguarding concerns being referred to the local authority, not all staff had received safeguarding training and not all staff understood their responsibilities in protecting people from abuse. Feedback indicated there were enough staff to meet people’s needs and on the whole, recruitment processes were safe. We asked the provider to immediately address shortfalls where they posed risk of harm to people. Although the provider gave us assurances they would do so after the first day of our inspection, our second site visit six days later found continued shortfalls in this area and additional ways that people and staff were being exposed to risk of significant harm. The provider could not demonstrate that people’s risks were consistently well managed. However, we saw some examples of how people’s risks and needs were responded to appropriately.

We identified a second breach of the regulations due to the provider’s poor systems and oversight of the quality and safety of the service. Despite the provider’s role in the local response to the pandemic and supporting people with COVID-19, they had not ensured their service was fit for purpose to safely meet people’s needs and manage infection risks. We needed to ask for immediate concerns around infection control to be addressed. We saw additional widespread concerns in relation to care planning to meet people’s individual needs and wishes. At the time of the inspection, relatives described the service’s communication as poor and we found there were no systems in use to effectively gather feedback to improve the quality of the service or to help inform person-centred care. The provider understood their regulatory requirements. The provider acknowledged our concerns and after our inspection, decided to suspend further admissions to the home whilst they addressed concerns with input and support from the local authority.

Staff told us they felt supported and welcomed recent improvements to the home. However, the provider’s training plans had not been maintained to ensure all staff received the training and supervision required for their roles. Poor quality care records, combined with staff training gaps, did not give us assurance that people’s needs could be effectively met at all times. Care staff and nurses described good communication