Rawreth Court

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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found during this inspection, and the provider was subsequently no longer in breach of this regulation.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Governance systems monitored complaints, incidents, safeguarding concerns and accidents, with outcomes reviewed through audits, meetings and provider oversight. Records demonstrated lessons learned were shared with staff through supervision, competency assessments and team discussions to improve practice. The registered manager responded positively to feedback during the assessment and acted promptly when improvements were identified.

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.

Due to the provider being an NHS service information sharing with partner agencies was seamless. The service also ensured that care needs and assessments were up to date, this ensured that when records were shared between services people’s needs were reflected in their care records so that care needs between services was met.

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.

We reviewed safeguarding events that had been raised at the service. We found that appropriate handling of safeguarding concerns had occurred. Investigations, analysis, lessons learnt and action plans all led to appropriate action being taken and events being handled in safe and effective way.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 and how they managed Deprivation of Liberty Safeguards (DoLS) within the service. Records showed applications had been submitted where people were potentially deprived of their liberty. The provider had oversight of DoLS authorisations and applications through governance systems, and staff considered the least restrictive options when supporting people. We identified some improvements were required to strengthen records of best-interest decision making and consultation relating to specific restrictive practices, however this did not affect people's day-to-day care or safety.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was, supportive and enabled people to do the things that mattered to them.

Care plans contained detailed risk assessments covering mobility, falls, nutrition, choking, positive behaviour support and equipment use, which were reviewed as people's needs changed.The service had a good insight into those that they supported, for example one person was in care as a child and so it was detailed that the term ‘care home’ could cause distress and that this should be avoided. Examples like this evidenced that people were involved in their care planning. People were able to participate safely in activities and opportunities that were important to them.

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

The provider had a robust maintenance schedule and regular safety checks and systems were in place. Fire systems, emergency lighting, legionella and water temperature checks were conducted regularly among many others. There were also regular checks done on equipment such as wheelchairs and beds used by the service. The provider through internal audits had identified a need to conduct fire safety drills more frequently and so these had increased in the 6 months leading up to the inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were sufficient to cover all assessed needs as well as care for those under 1-1 supervision. Staff all had relevant training according to their roles and there was a high focus on palliative and end of life care training. A staff member told us, “[Registered manager] is all for people progressing in their career, if you want to do training, [they] arrange it and it is great for people’s development. Very supportive and very encouraging.”

Whilst the above gave assurances that staffing was safe and effective we did find that not all recruitment checks could be evidenced whilst on site. The provider was able to give some assurances, however some details of checks completed were missing. The registered manager accepted this and was implementing measures to rectify this concern.

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

Comprehensive infection prevention and control policies, training, cleaning schedules and audit systems were in place and supported through management oversight. Internal and external audits provided assurance that standards were maintained. Staff demonstrated a good understanding of infection prevention measures. Staff had access to appropriate personal protective equipment (PPE) and were observed using effective techniques such as hand washing to prevent infections. At the time of the assessment, there were no outbreaks of infections.

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

There were systems and processes in place to manage medicines safely however, these were not always robust, and staff were not always following them. Staff were not following manufactures instructions regarding rotation of topical medicine patches and were not always recording where the patch had been applied. This can lead to skin irritation and accidental overdose due to build up of medicines in the skin. Staff did not always keep accurate records of medicines administration. Time sensitive medicines did not have the administration time recorded; The provider could not demonstrate that staff had a robust system in place to ensure medicines were not given too close together. This was raised with the service and a new system put in place immediately. Staff did not always keep accurate records when administering when required (prn) medicines. Staff did not always accurately record medicines administered to support people with distress and agitation. Paper and electronic records did not always correspond and some entries were missing. This meant staff could not accurately audit the use and effectiveness of these medicines. Staff did not double sign handwritten Medicines Administration Records (MAR) charts to ensure they were accurate as per NICE guidance.

Monthly medicines audits were in place however, they had not identified the areas requiring improvement found during this inspection.

Medicines, including controlled drugs, were stored securely and in line with legal requirements. Room and fridge temperatures and emergency medicines were checked daily. People received their medicines as prescribed, including medicines administered covertly. People received regular medicines reviews from healthcare professionals including high risk medicines such as antipsychotics. Care plans and risk assessments were in place to support staff to administer medicines safely. Staff had received regular training and competency assessments to carry out their role.