Dunraven House and Lodge

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

Staff did not always receive adequate training to enable them to safely support people with either mental health or medical conditions. Health risk assessments were in place, but they did not always mitigate known risks so people’s conditions were not always well managed to reduce the risk to their health and well-being. For example, we saw one person, who had diabetes, had sugar levels which were recorded by the service as extremely high for a number of days. The provider had failed to highlight this or support the person to contact their diabetic nurse. Inspectors saw that medicines were being managed safely, however they were not being managed in line with people’s personal preferences, with no consideration to, for example, where people would like to take their medicines or if they wanted to self-administer.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experience was mixed as some people told us they felt staff did not support them safely. One person told us that when they raised things with managers they were ignored. We saw another person being ignored by staff when they asked a question. However, others felt staff were good at their jobs. One person we spoke to said the staff were “good to me” another person told us that “most carers are good”.

Staff were not always able to identify how best to support people. Neither did they always recognise the individual needs of people to ensure people were safely supported. For example, 1 person who was at risk of poor mental health was identified by staff in care records as experiencing a deterioration in their mental health. However staff did not then ensure adequate support was provided to them to assist them. The registered manager told us they felt management members having specific training was “adequate to support all people as there were always a manager around”. Staff told us most training was by video and at the end of the training they were being told the answers to the quiz by the manager training them to ensure the provider could demonstrate passed the modules they were watching. This meant leaders could not be assured staff were competent to support people’s needs in practice.

The provider could not demonstrate they had a process in place to review and learn from significant events and incidents. This meant they were not promoting a culture of learning to support people safely and improve the service. Nor could the registered manager demonstrate they adequately reviewed records to take actions and learn from them. For example, one person’s records demonstrated a change in their wellbeing but there was no evidence that the registered manager had acted upon that change.

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.

One person told us when they had raised concerns they had not been listened to. They told us because of this they had stopped raising issues with the managers as they felt nothing would be done for them. However, other people felt they could raise concerns to staff and they knew who they felt would act upon their concerns.

Staff we spoke to could identify types of abuse. Staff told us they would report any issues to management if they identified someone who needed to be referred to safeguarding. The registered manager told us the local authority Safeguarding Adults procedure was available to staff, however those staff we spoke to did not know where to find it.

We saw that safeguards were not in place to ensure people were always safely supported. There was a large greenhouse in the back garden that did not have safety glass. There were no risk assessment in place in relation to this. When the inspector pointed this out a manager they said they would address this issue.

The provider had a safeguarding policy and procedure in place and were aware of the local authority’s safeguarding guidance. We found 1 person had not had a referral to the safeguarding team as the registered manager had not recognised the significance of regular incidents of distress that had been seen by staff. The registered manager had not followed the local authority guidance which states repeated low level incidents should be reported to their safeguarding team. This put people at risk not being safeguarded from avoidable harm

People had risk assessments in place, however people we spoke to told us they were completed without their input or engagement. This means people were not being empowered to take risks appropriately.

Staff and managers we spoke to were able to identify risks. However, when asked about risk management, one manager told us “We make them (risk assessments) and then share with the person”.

We saw from people’s records that the provider was not fully involving people in managing their risks. A manager was signing off care plans and risk assessments for people which meant the provider could not demonstrate people had been involved in their plans or agreed to them. During the inspection we heard staff telling people what they could do rather than discussing choices and any associated risks with them. One person’s records demonstrate they were not being safely supported in relation their risks. When asked about this the registered manager stated that because the person and capacity they could not do anything. However, to ensure the service is working in line with current guidance the provider should proactively engage with people in relation to choice and should be able to demonstrate they have done this.

The process for identifying risks was service-orientated, and people were not included in developing their risk assessments nor enabled to make decisions about risk-taking. For example, when we spoke to a manager about managing risks they said they would decide if people could take risks and would not allow a person to take risks if management decided they shouldn’t. This approach failed to recognise people’s rights and preferences. Despite there being a person living at the service who had a history of breaking glass to self-harm, processes were not in place to identify risks for people in relation to glass throughout the service. When this was highlighted to the registered manager, they took action to ensure a risk assessment was put in place. There was no process in place for identifying and reducing risks for other people who may at times self-harm. When asked, the registered manager said they “did not have people who did that kind of thing living at the service”, however, when care plans were reviewed, inspectors found there were at least 3 people at the service with these risks. This put people at risk of increased harm. Fire risk assessments did not always recognise some people’s mobility needs. We reviewed the evacuation plans of 2 people who were wheelchair users with significantly reduced mobility. The evacuation plans for these people did not have the detail needed in them around their mobility needs to support safe evacuation in case of fire if they were in their rooms. One person’s evacuation plan stated they could be carried from their room downstairs in their wheelchair which would put them and others at risk. The provider had not completed any recent nighttime evacuations or simulations to ensure people could evacuate in a timely way with less staff in the service.

People told us they felt safe within the house, one person said they were moved to the house from supported living because they had been falling and that managers could “keep a closer eye” on them. However, we saw the environment was not always safe.

Staff told us they felt the environment generally safe however when they had highlighted issues with management about, for example the tables being laid with glasses for lunch some hours before they were needed, this had been ignored.

The service was not always being run safely. Some aspects of the environment put people at risk. There was a large greenhouse in the garden that did not have safety glass in it, nor did the display cabinets have safety glass. Whilst walking around the service we found there were unsafe handrails within the garden and a hose pipe laid across a footpath., causing a trip hazard. These issues were pointed out to a manager who took actions to rectify the issues. Despite supporting people who may harm themselves the provider had items such as knives on display in the dining room. When asked the registered manager said they did not have people who would use these items. However, when we reviewed care plans we saw there were people within the service that could harm themselves.

People told us they liked staff, and they knew how to support them safely.

Staff told us they mainly completed online, or DVD-delivered, training which was being assessed by a service manager. However, the service manager’s train the trainer qualification was out of date, meaning the registered manager could not be assured that the training had been delivered appropriately nor that it had been understood by staff in line with current guidance. The registered manager told us they were using some face to face training too, but this had significantly reduced with Covid. However, staff had attended the service’s identified mandatory training and there was a drive to support staff to complete NVQs in care if staff wished to. Staff told us they had not received any training in diabetes and epilepsy despite there being people with these conditions living at the service. Managers who had been trained were not always directly supporting people and they may not have been available in a crisis or identify and respond to signs and symptoms to avoid a health emergency. CQC asked the provider to urgently look at training for staff and to forward a training plan to demonstrate they could support people safely. Staff told us that at times there were not enough staff working in the service to be able to safely support people. Staff told the inspectors they did not always have regular supervisions, however the registered manager said staff were able to access supervisions.

Staff did not appear to know how to safely support a person with self-harming tendencies appropriately. For example, despite having a service user with a history of self-harming with a glass, we saw glasses being laid out for lunch in the dining area at 9.30am and then being left unsupervised for anyone to have access to. We saw staff did not always interact with people. Several people were observed sat in chairs with no engagement from staff, and we also saw a member of staff ignoring a person when they asked for assistance. We saw the service was staffed according to their rota the service’s buildings on the days we visited the service.

People were not always being recruited in a safe way. Some people had gaps in their employment history. The provider could not demonstrate they had sought clarity in relation to the employment gaps nor had they mitigated any risks in relation to the gaps in employment. Staff told us they had started lone working in the service before they had received an enhanced clear Disclosure Baring Service (DBS check). The provider had not taken steps to mitigate the risks associated with this. The provider had also not kept records of interviews or evidence of identification checks having been completed which is not in line with Schedule 3 requirements of the Health and Social Care Act 2008 Training records showed staff were not always trained to support people safely. There was no mental health specific training available to staff. Nor was there training for staff about people’s individual support and health needs. This meant the provider could not be assured people were being supported safely and by appropriately trained staff. The local authority identified their concerns about this before the assessment. Managers told us this was being organised as a matter of urgency, after being prompted about the importance of training for all staff to meet people’s needs. There was a system in place for supervising staff, but this was not consistent followed. We saw supervisions were being completed but records of these were not always clear as to what actions needed to be taken. Some staff told us they did not receive regular supervisions and that when they did concerns they had raised were not addressed.

The registered manager employed cleaners to keep the service clean. Cleaners we spoke to told us how they ensured they followed infection prevention and control guidance when cleaning. However, we identified waste bins in the bathroom did not always have liners in, in line with national infection prevention and control guidance. We highlighted this to the registered manager who said they would take steps to address this.

People we spoke with said staff supported them to take their medicines. People administered their own topical creams and ointments. We spoke to people about this, and they told us staff helped them if needed. They said when they were running out of creams, staff would order replacements for them.

Staff we spoke to understood their responsibilities in relation to medicine management. We saw staff recorded the effectiveness of some PRN medicines but this was not being done consistently. We discussed this with the service’s medicines lead who said they would speak with staff and ensure this happened going forward.

The service used an electronic medicines administration system. This enabled the medicines lead to oversee medicines across both sites. Medicine administration records showed people received their medicines as prescribed. When medicines had not been administered, reasons were recorded. We saw medicines were being stored safely. Risk assessments had been completed for any flammable creams. People had received regular medicines reviews with a GP or other health professionals. We saw records which showed this happened. However, medicines were being administered from a large medicine cabinet which was wheeled around the service. This meant medicine support was not delivered in line with Right Support, Right Care, Right Culture guidance which states people’s support should be personalised to maximise their rights and choices.