Rastrick Hall and Grange

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

At our last inspection we rated this key question requires improvement. At this assessment the rating remains unchanged. We looked at all of the quality statements for this key question. We identified a breach of the legal regulation in relation to safe care and treatment. Risks to people’s health and welfare were not always managed safely or consistently. People and their relatives expressed concerns about the safety of the care provided. Action to learn and improve was not consistently taken when concerns were raised about the safety of the service, or how the quality of the care could be improved. Systems and processes were in place to ensure medicines were managed safely, but they were not always effective. However, robust and safe recruitment and vetting processes were in place. Systems were also in place to provide and monitor staff training and completion of supervisions. Care and support was planned and organised in collaboration with people and partner agencies, to ensure continuity of safe care across different services.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives were not always confident that lessons were learned in response to issues raised about improving care. For example, two relatives told us they were not confident that improvements were made to their family member’s care when they had fed back about issues that concerned them.

Staff said they felt able to raise any safety concerns and were confident they would be dealt with. They explained how feedback and actions in response to incidents or accidents were sometimes shared in handovers and team meetings. The manager told us how they share what is happening in the service with staff to enable them to understand where changes are needed. A member of management acknowledged that learning from events was not currently fully embedded at the service. Staff huddles had recently been started to discuss things that had happened and to encourage staff involvement in making changes and improvements to reduce recurrence. Staff demonstrated learning from feedback during the inspection. Their actions evidenced an understanding of the issues raised and that they took action to affect immediate and sustained change.

Systems were in place to take learning from accidents, incidents and complaints. Lessons learned documents had been completed and staff had signed to say they had read them. Incidents were also discussed in staff meetings and, where appropriate, the manager had a discussion with staff involved and staff completed a reflective practice. However, further time was needed to embed this into practice. Safeguarding overview documents were in place which included a lessons learned section. However, this section had not always been completed. Where it had, there was evidence of follow up action. For example, where it had been identified that staff needed extra training in positive risk taking, this had been completed.

A person we spoke with told us they were confident staff would organise medical help for them if they needed it.

Staff worked with health and social care professionals when people’s needs changed and a move to a more appropriate care setting was needed. Staff said information about people who were new to the service was provided at handovers and team meetings. The manager told us about a person who had been admitted to the service from another local authority. The person needed to attend regular medical appointments, for a serious condition. To ensure the person was not making long journeys to attend appointments, the home worked with the specialist at the hospital to enable the person to attend appointments and receive any treatment locally.

A visiting healthcare professional told us they were not confident that staff always followed their advice in relation to follow up care. For example, in relation to the care of people’s skin conditions.

Prior to being offered accommodation at the service, people’s needs were assessed to make sure their needs could be met. We saw examples of detailed pre-admission assessments. The electronic care record system also included a form for staff to complete and print when a person was using hospital services. The form gave hospital staff information about the person and contact details for family and involved health care professionals. Where a ‘do not attempt cardiopulmonary resuscitation (DNACPR) was in place, this was also uploaded to the document.

We received mixed feedback from people and their relatives as to whether they felt the care they received was safe or not. For example, comments included, “It’s not bad here. I’m safe here”, “It’s as fine as it can be. I have no worries about safety”, “There’s not enough staff and no consistency” and “No, [my relative] is not safe: it’s inconsistent.” We also found minutes of a relatives meeting that had been held indicated relatives were concerned about the safety of the people living at the home.

Staff were able to explain the types of concerns that would need to be reported as safeguarding, and the appropriate process to follow. They said that when concerns had been raised, they had been dealt with quickly and appropriately. Relatives and residents were encouraged to raise or share concerns during regular meetings held in the home. The manager had also held successful drop-in sessions for families to speak to them about any concerns and more were planned. The manager had identified the need for improvements in the safety of the service and wanted to work collaboratively, with the local authority safeguarding team, to address these issues. Staff were generally able to explain the purpose of the Mental Capacity Act 2005. They said Deprivation of Liberty Safeguards (DoLS) information was accessible on their devices but were not able to give examples of people who had them in place and what this meant for them.

On the first day of the assessment, we observed people had been left unattended in a lounge/dining area. The hot trolley containing lunch had been left accessible to the people in the communal space. We raised this as a concern and the manager attended immediately.

At the time of this assessment, the local authority safeguarding team was working very closely with the service to address issues. For example, the provider had become aware of an issue where, under a previous manager, safeguarding referrals had not been made as needed. The provider had addressed this by thoroughly reviewing people’s records and had made many retrospective safeguarding referrals. Safeguarding referrals had since been made appropriately. There was a robust safeguarding policy and procedure in place. The safeguarding policy was on display in the staff room. There was also a poster on how visitors could raise a concern on display in both reception areas of the home. Care records indicated where a person had a DoLS in place and when a best interest decision had been made. However, it had not been recorded who took part in the decision process and what options had been considered. The new manager had identified that the overview of people’s DoLS was not up to date, and they were unsure about any current applied conditions of care. They were in the process of addressing this with the local authority DoLS assessor. Where a condition on one person’s DoLS had been noted, work was taking place to make sure the condition was met.

We received mixed feedback regarding the safety of people’s care. For example, some relatives we spoke to raised concerns about the safety of their family member’s care. There were concerns about staff not following advice from health care professionals and concerns about items essential to people’s wellbeing, such as glasses and hearing aids, going missing.

Staff told us that people’s care plans and risk assessments helped them understand their needs and wishes. However, the management team were aware of the need for improvements to risk assessments and were in the process of addressing this along with reviewing care plans. For example, the manager told us about how, following the development of a positive risk assessment in relation to mobility, the person involved had experienced less falls.

We observed people in communal areas were at times left unsupervised. However, once we raised this as a concern, we found it improved during the course of our assessment.

Systems and processes were not always effective in monitoring and managing risks to people. For example, risks to people's health and welfare were assessed using several recognised tools. However, these assessments did not give detail of the actions staff needed to take to minimise the risk or an overview of the efficacy of staff actions in managing the risk. We found 25 people living at the service had been identified as losing weight. Whilst some of these people remained within the normal weight range, four people assessed as severely underweight and one person assessed as underweight were continuing to lose weight. Care plans and related records did not always evidence that the risk of further weight loss was being adequately addressed for these people. For example, the most recent monthly weight overview detailed ‘missed weight’ for two people who had been assessed as being severely underweight. We also found the air mattress for a person who had been assessed as being at risk of pressure damage was set to 60kg however, the person’s weight records showed they weighed just less than 50kg. This meant the mattress would not provide the correct pressure relief. We fed this back to the management team who made an immediate check of air mattress settings to make sure they were correct.

People and their relatives told us the environment was not always safe. For example, when speaking to a person in their room, who was wearing multiple layers of clothing, we asked if they were warm enough as the room felt cold. They said they were used to the room being cold and did not mind it. However, the relative of another person told us their family member’s room was cold because the radiator didn’t work. A relative also told us their family member became agitated by another person going into their room.

The manager told us they were looking at how a room, currently used to store activity equipment, could be used to provide people with a quiet area to possibly meet with families or spend quality time with other people living at the service. The provider was taking steps to address the temperature of people’s rooms.

We observed mixed practice regarding the safety of the environment. People were able to move around communal areas freely and without obstruction. We also saw banners with ‘stop’ signs had been placed across the bedroom doorways of people who liked to stay in their rooms with their doors open. This was to deter people, especially those living with dementia, from entering their room. The manager told us this was effective. However, we found people in bedrooms did not always have their call bells within reach and not all people who needed wheelchairs had access to them.

The provider had processes in place to routinely monitor and maintain the safety of the premises. For example, relevant safety certificates were in place and staff noted issues in relation to maintenance of the service in a communication book for the maintenance man. However, the processes were not always effective with regards to equipment used in the service. We found people did not always have the equipment they needed for mobilising safely. For example, on one unit several people used a wheelchair which we identified as belonging to a specific person. Staff told us it was the only wheelchair on the unit. Appropriate tables for people who wanted to take their meals in the lounge areas were also unavailable. The manager ordered a number of these following our feedback.

We received mixed feedback from people and relatives in relation to staffing. For example, one relative said there were staff available in the lounge, whilst others expressed concerns about staff availability and competence. We found staffing had previously been raised as a concern during a relative’s meeting.

Staff told us they received training that supported them in their roles. Staff who were new to the service said their induction had adequately prepared them for their role. For example, 1 staff member told us, “The courses here are good, they’re really clear at explaining what you can and can’t do and who you should tell if you’re worried about something.” Some staff raised concerns about staffing, particularly at mealtimes. A staff member said, “I feel guilty when I have to juggle between making sure someone gets their breakfast and supporting someone who needs the toilet because they shouldn’t have to wait for either.” During the assessment the manager introduced an initiative where all available staff, including visiting members of the management team, provided support at mealtimes. The manager told us they were seeing some good results from this and had identified where improvements could be made. The manager told us they used a dependency tool to work out how many staff were needed. They acknowledged that the dependency tool used did not consider the layout of the building and told us they routinely staffed above the levels suggested by the tool.

We observed times when staff were not available in lounge areas because they were supporting people with their needs. We also observed people having to wait for support when they needed more than one member of staff to assist them, or because the staff member in the lounge was mindful that they shouldn’t leave.

Deployment of staff was not always effective, which resulted in people having to wait for care and support. We also received consistent feedback that staffing was a concern during our assessment. Robust and safe recruitment and vetting processes were in place. Systems were in place to provide and monitor staff training. At 90% completion the service was below the provider’s compliance rate of 95%, the manager explained this was due to the recent influx of new starters who were still in the process of completing their training. New staff confirmed this was the case. A member of staff had been appointed as ‘Induction champion’ to support new staff through their first weeks in the service. Processes were in place to monitor completion of staff supervisions. The manager was currently completing supervisions that had not taken place in the previous month, due to needing to prioritise investigations into safeguarding concerns.

Some relatives we spoke with raised concerns about the standards of cleanliness. For example, one relative said, “It’s ok clean, but it could be better.” We found people needed better support with their personal hygiene. For example, some people’s nails were dirty and people who had eaten in their rooms were not supported in a timely way to clean up food spillages.

Staff told us they had sufficient access to Personal Protective Equipment (PPE) and cleaning products. Staff said they helped to clean up spills if they were with a person however, this was not always observed to be the case. The manager told us cleanliness had been identified as an issue when they commenced in post. They had introduced new cleaning schedules and improved the deployment of the domestic team.

On our visit it was identified that additional cleaning of one person’s room was required due to them preferring to eat in their room and the domestic team put a plan in place to manage this. We raised our concerns with the provider and found standards of environmental hygiene improved during the assessment.

Systems and processes in place were not always effective in ensuring cleanliness in the service and for people. We found improvements were needed in relation to making sure the home was clean. For example, on the first day of the assessment one person’s bedroom had spilled tea on the floor which had dried. There was food debris on their bedframe and the commode pan in their ensuite was dirty. Another person’s urine bottle had not been emptied and we noted some tables in the dining area were not clean. We also had to ask a member of care staff to clean one person’s over chair table before serving their food. The provider responded to our feedback, and we noted standards of cleanliness improved on our subsequent visits. A recent inspection by visiting professionals had identified serious issues in relation to the main kitchen and the kitchen areas on each unit. The newly appointed chef had addressed many of the issues in the main kitchen. However, we saw these areas needed more thorough cleaning. Guidance for managing outbreaks of infection were in place and a recent outbreak of respiratory infection had been managed well, in conjunction with appropriate partner agencies.

Records reviewed during the assessment, showed that Parkinsons’ medicines were given on time, which is vital for the person’s wellbeing and safety. People that were prescribed creams had paperwork to show where these had been applied to ensure maximum efficacy. During the assessment we witnessed several occasions where medicines were not signed as administered due to lack of stock. This was not always documented on the person’s records and escalated in the correct way. When asked about this, the manager noted there had been new staff recently and extra training was being carried out to improve this. Some people had handwritten medicines administration records for medicines needed ‘ad-hoc’ between regular doses. These were not always legible, and some handwritten records could run the risk of duplicated doses being administered.

When speaking to carers during the assessment, they mentioned their training was a mixture of online and in-house mandatory modules. The manager told us they were organising more face-to-face training to improve systems which were already in place. Thickeners prescribed to aid people with their dietary and swallowing needs were kept in the dining room of the home. National Institute for Health and Care Excellence (NICE) guidelines state these should be kept in a locked cupboard to avoid accidental ingestion, which could lead to choking. When asked about this, one carer said, ‘this was where it has always been kept’. No accompanying information from the Speech and Language Team (SALT) was present with this, which could lead to a risk of people being given thickener in wrong quantities and consistencies for their required needs. One senior carer said they don’t routinely have problems with medicines being out of stock and they have a good relationship with the supplying pharmacy. They knew the process to follow if running low on a medicine.

Systems and processes were in place to ensure medicines were managed safely, but they were not always effective. For example, fridge temperatures that were recorded outside of the recommended range to ensure the safe storage of medicines, were not routinely acted upon which could put the medicines’ effectiveness at risk. Controlled drug checks were also not being carried out as frequently as the home’s policy specified. This is a risk, due to the nature of the medicines having the potential to be misused. People that had as and when required, ‘PRN’ medicines prescribed, had accompanying protocols in place to show staff how and when to administer these safely and effectively. However, when PRN doses were administered, there was lack of documentation to show when these were given and the outcome. Regular audits were carried out to ensure that procedures were followed and there was a system in place to record medicines errors and incidents, however these had not always been effective in identifying where improvements were needed.