Archived: Ravenhill Way

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

A relative confirmed they were kept informed on what was happening at the service and had no concerns about their relative’s care. They felt their loved one felt safe living at the home. Staff confirmed they spoke with each other regularly about people living at the service and had a process to record important information within handover and communication records. Meetings took place at organisational level to determine whether any specific areas of service provision required improvement, however, we only received evidence of one meeting. Opportunities to learn lessons could have been missed. Staff were knowledgeable about what constituted abuse and harm and knew what actions to take in reporting concerns. However, senior staff did not always identify allegations of abuse or make referrals in line with their policy. We found incidents that met the threshold for a safeguarding concern were not always shared with the local authority and CQC. Two risk assessments relating to a person were incomplete and did not include the risk type and level of risk, including one risk which CQC identified during our assessment. Staff told us there was not enough staff to meet people's social needs and spend time with people out in the community. The registered manager was unable to demonstrate staff had been recruited safely. We identified shortfalls in staff training. Not all staff had been appropriately trained to meet people’s needs and keep them safe when at home. We found shortfalls with the maintenance and upkeep of the home, as well as the hygiene and how the risk of infection was managed in the home. Certain rooms such as bathrooms were not clean which put people at potential risk of cross contamination.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People could raise concerns, complaints, and compliments. A relative we spoke to knew who the manager was and felt able to approach them. They said, “I get regular emails, telling me what is happening, and updates. The [registered manager] has always contacted me to bring up issues.” The relative also confirmed they got regular telephone calls from the service asking if everything was okay.”

Organisational risk panel meetings had not taken place in the last 12 months but were due to re-commence. Other organisational meetings took place to look at themes across all services to determine if any specific areas of service provision needed addressing. A record of this meeting could not be provided. Serious incidents were reviewed by the provider’s quality team, and any learning or actions, were implemented. However, at a local level the registered manager advised the system needed to be improved, referring to previous incidents. They said that incidents should be discussed in a team meeting to allow staff the opportunity to give an opinion; however, team meetings were not taking place at the time of our assessment. Discussions between staff at service level in relation to incidents and accidents and safeguarding concerns had not been recorded. Staff confirmed no complaints had been received. The provider took immediate action and implemented a new monitoring schedule for team meetings. Staff confirmed they spoke to each other regularly during shifts and handovers. They used the communication book and handover records to record vital information. They advised senior management visited the service to speak with them. Any concerns relating to people living at the service would also be discussed in supervisions. If other professionals share concerns about people with staff, this information would be reported to senior staff as per the providers policy. No service user meetings had taken place since January 2024, this meant people living at the service were not regularly given the opportunity to ‘speak out.’

Minutes of staff meetings were received from 2023, evidencing that several aspects of the service were discussed, including the environment, safeguarding and people living at the service. However, team meetings were no longer taking place. There were no specific records to show lessons learned had been discussed or shared with all staff. This meant the opportunity to reduce the risk of harm for people may have been missed. However, there was evidence the service had sought feedback from people and checked to see if they were happy with the care they received.

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.

Relatives we spoke to did not raise any concerns in relation to safeguarding or any other safety concerns. They told us, “The staff are genuine, the registered manager has done a lot to support [name of person] and I have seen a significant change. I’m happy for [name of person] to stay at Ravenhill.”

The registered manager confirmed in the past they had planned ‘safeguarding’ themed service user meetings to discuss safety with people living at the service and spoke to people regularly during their key worker meetings. Any safeguarding concerns would be shared during handover, along with outcomes and lessons learned. The registered manager was happy with staff’s knowledge of safeguarding and confirmed they complete safeguarding training annually. Senior managers fed back they were unable to access the services safeguarding records in the registered manager’s absence due to moving to a new system. However, these records were provided at a later date. Staff confirmed they had access to the safeguarding policies and protocols and were able to describe different types of abuse. Staff knew how to escalate concerns about people if they were worried no action had been taken.

On our first site visit, shortly after we arrived, a staff member brought a person to meet the inspection team unnecessarily. [Name of person] presented unclean and appeared uncomfortable when coming to meet the inspection team. During the rest of our time at the service staff interacted with people kindly and respectfully. On our 2nd visit, we had met [name of person] a few times and they came to say hello. They appeared with ripped clothing. The senior staff member on duty supportively suggested they pop back to their bedroom to replace their clothing.

The service did not have effective safeguarding systems in place to help protect people from the risk of abuse. The registered manager kept a log of safeguarding concerns. However, this record was unclear and did not provide information relating to incidences, and any actions taken as a result. Following our initial review the senior manager produced an updated safeguarding log, it became clear that some incidences had not been referred to local safeguarding or CQC. Three notifications were submitted retrospectively, and the service liaised with the local safeguarding team.

A relative confirmed they were contacted if there were any incidences to report. But they were unsure how often their loved one’s care records were reviewed.

Mixed feedback was received from staff about the safety of people living at the service. Staff were knowledgeable about the needs of people they cared for. Staff were able to tell us what protocols were in place if emergency help was needed. They were able to describe how people’s risk assessments were completed to promote people’s independence and were able to provide examples of how positive risks were taken to support and respect people to make choices about their care. Staff confirmed they have access to all risk assessment records.

During our first assessment we observed several environmental and infection prevention control risks which were not noticed by staff until we brought it to their attention, including several hazardous cleaning products on display at the service. (see safe environment section for more details). There was a lifesaving defibrillator installed at the service.

We reviewed a recently updated care plan; however, it was inaccurate. The risk assessment records for one person were not up to date and did not contain current information about risk levels. For example, the environmental risk assessment record specifically relating to evacuating in the event of a fire did not indicate risk type, likelihood, consequence, and risk level. The risk assessment relating to preparation of food was missing. This was provided at a later date but again did not include information relating risk or whether other people at the service may be at risk of harm. Care plans did not always describe recent incidents and future risks. Staff recognised incidents and reported them appropriately. Accidents and incidents were recorded on the provider’s internal systems and investigated by either the registered manager or senior management team, depending on the severity. However, the logs provided during our assessment relating to incident and accidents did not provide a detailed description of these incidences. It was unclear whether referrals had been made to other professionals, whether there were any actions post incident, whether CQC had in fact been notified and whether there were any lessons learned. Upon further review, it became clear that an incident of aggression involving one person at the service had not been reported to either the CQC or the local authority safeguarding team. (see our well-led section for more about records). Fire drills involving people living at the home were documented as having taken place. People had Personal Emergency Evacuation Plans (PEEP) in place to support staff to safely evacuate the home in the event of an emergency such as a fire.

A relative advised us they were unsure whether their loved one’s personal possessions were safe; due to them tending to throw items away. However, their bedroom door was lockable.

People living in the service were supported by staff to clean their home. Staff advised us they try to encourage people living at the service to get involved in cleaning. Staff were required to clean the communal areas. We requested more information from the service about the collection of bulky refuse, after it became apparent the used mattresses were being stored in the garden, which could potentially be a health hazard to others living at the home. Staff informed us it was a ‘fight’ to get these items collected. Staff told us the garden was used mainly as a smoking area and not for anything else, the garden requires improvement to enable people living at the service to have full access to it. Staff also told us other areas in the home require upgrading and re-furnishing. Some staff confirmed they had completed fire marshal training and fire safety training. Staff were able to describe what measures they needed to take to reduce the risk of people catching and spreading infection.

Several environmental concerns were identified. During our first site visit we observed several hazardous cleaning products stored in an unlocked cabinet. Staff advised the products could be a potential risk to one person living at the home; however, they were away from the care home at the time of our site visit. On our second visit the cleaning products had been removed and stored elsewhere. There were multiple environmental concerns including damaged flooring and broken cupboards in the conservatory, peeling fabric on a communal sofa, an overgrown garden; in one lounge the trees were growing through a window. Despite cleaning records being complete. We found nasal mucous stuck to the wall in one individual toilet. Other painted walls were badly stained. Pull light cords were unclean throughout the home. A damaged bath panel plus a heavy build-up of limescale on one shower screen. Within individual toilet and bathrooms, we found urine-stained toilets seats, wall tiles and flooring. There was a missing towel rail and broken hand towel dispenser in other bathrooms. Bin liners were not present in any of the bathroom bins. Adequate supplies of personal protective equipment (PPE) were available for use when required. The service acted upon these issues shortly after our site visit and confirmed some improvements have been completed to ensure a safe environment, including deep cleaning of toilet and bathroom facilities, fitting a new bath panel, fitting new flooring, installing a new wall mounted cigarette bin and painting walls in two small individual toilets.

Most staff had received training in infection prevention and control. Regular IPC checks had been completed by the registered manager, but these did not identify the IPC and environmental concerns we found during our site visit. Cleaning schedules were observed evidencing cleaning had been completed. However, we found several areas around the home that required deep cleaning. Regular safety checks were carried out at the service. An internal health and safety audit had not been completed by the service, although an external company had completed one of behalf of the landlord. This report confirmed a used mattress which had temporary been placed in the garden was still there 3 weeks and 1 day after it was removed from the house, along with a second used mattress. (see our well-led section for more about records). A property works proposal was shared however the works required to improve the environment had been scheduled to be completed within the next 1-2 years.

Relatives gave us positive comments about staffing. One relative said, “I think staff have the right experience, [Name of staff member] will call me, and they are good.”

Staff told us there were periods where staff may be required to work alone. However, if people living at the service required support with appointments or collecting medication, management ensured there was always an extra staff member available . Mixed feedback was received from staff as to whether there were enough staff to meet the wellbeing needs of the people living at the service. One staff member said, “There are times when we are often lone working, if this happens, then people are restricted from attending activities in the community.” Another staff member said, “We do not have enough time to meet people’s needs. If you are taking someone out into the community, you must rush back as medicines are administered at 4pm.” Mixed feedback was received from staff regarding supervisions; some staff advised they had attended a recent supervision, and one staff member said, “I have one every now and again.” Senior management confirmed staff appraisals were last completed in 2022, however the process was currently under review. One staff member said, “If I need to have one, I will ask for one and I will get one.” Agency staff were used at the service to support care provision, however regular agency staff were used to provide continuity of care.

During our onsite visits there were enough staff on duty to support people with their needs. Although we did not observe a person going out into the community with 1:1 staff support. Staff interacted kindly with people, and they appeared to be comfortable with staff.

The registered manager had not ensured safe recruitment practices were being followed. Prior to new staff commencing employment the registered manager was required to check staff suitability for their job role. However, on reviewing 2 recruitment files we found full career history was not evident or had been fully explored. There were missing references within recruitment files, and it was not clear from records whether staff had been consulted as to whether reasonable adjustments were required to carry out their role. However, this information was provided at a later date. Essential training information within induction records had not been completed. One competency record we reviewed had several blank entries. New staff received an induction, and it was evident that supervisions and competency checks were taking place for these staff. Staff rotas we reviewed confirmed that over a period of 18 days, there had been 6 shifts when staff were lone working. This could have a potential impact on people’s care. The registered manager had no oversight of staff training. Not all staff had completed essential training to provide safe and effective care. Relief staff working at the home had only completed 3 modules of training despite commencing work at the beginning of the year. For example, we found staff who lone work had not completed fire safety and fire marshal training as well as challenging behaviour and de-escalation techniques. Specialist training for self-harm and suicide awareness had not been scheduled at the time of our assessment. Specialist training in mental health awareness, and other relevant health conditions had not been completed. 3 staff members had not completed basic life support and first aid. The service took immediate action and provided us with a full career history for all staff along with an explanation of gaps, some training modules were scheduled following our feedback.

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.

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