Delrose

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

We assessed all the quality statements in the key question of safe. The overall rating for this key question is requires improvement. The system to record, report and analyse incidents was ineffective in safeguarding people from coming to harm or reducing the risk of reoccurrence. The provider had imposed restrictions around people accessing parts of the home. They were not able to demonstrate how this was least restrictive. This was a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems and processes to ensure that people received medicines safely were not effective. The providers governance processes did not always mitigate risk, identify issues and learn from medicines related incidents. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider failed to ensure they completed robust recruitment checks when employing staff. This increased the risks that unsuitable staff may be employed to work with people. This was a breach of Regulation 19 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff had not all received the depth of training or ongoing support needed to in their role. Some staff were not knowledgeable about people’s needs or motivated in their role. This was reflected in the quality of support people received. This was a breach of Regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People’s care plans did not always contain sufficient detail about how staff should manage risks related to people’s medical conditions, health and behaviour. Relatives and staff told us that risks were not always effectively managed. The provider was working to improve the safety and suitability of the service, including ongoing actions around fire and water safety. The service was clean and hygienic and there were effective infection control policies in place.

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 were unable to give us feedback about their care. Therefore, where appropriate, we spoke to 5 relatives about their family member’s experiences of receiving support and care. We also spoke to an advocate, who had recent experience working with 2 people living at the service. Relatives expressed concerns that incidents were not managed appropriately, record keeping around incidents was not complete and communication with families was poor in relation to events. Comments included, “I only heard about [My relative’s] fall from a carer on my visit and thought that they [the provider] should let me know”, “One [staff member] could not tell me about how [my relative] got the cut on his leg. They just did not know” and, “There is not enough information in the notes about [my relative’s] behaviours."

Staff told us they knew how to report incidents appropriately. However, they did not always receive feedback about the outcome of investigations to promote future learning. Staff said the lack of consistent management was a factor as they told us they had reported concerns to management staff, but nothing was done. The area manager had recognised the impact of not having a consistent management structure in place and had based themselves at the service to support staff and oversee how incidents were managed.

There was not an effective system in place to report, investigate and act upon incidents. We reviewed the provider’s incident log from 2024 and found little detail of actions taken in response to incidents, many of which were incidents related to repeated behaviour or situations. This meant there were missed opportunities to learn from incidents and improve the quality of support. This put people at increased risk from subsequent incidents after previous concerns had not been fully addressed.

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to 5 relatives about their family member’s experiences of receiving support and care. We also spoke to an advocate, who had recent experience working with 2 people living at the service. Relatives raised concerns around arrangements to ensure people had access to healthcare services. In particular, their family members missing appointments, the provider not involving families in planning and attending appointments, not receiving feedback after people had attended appointments. Relatives were concerned about how this affected their family members health. Comments included, “[My relative] missed a GP appointment but nothing was written down as to why and any follow up action. Staff just said that he did not want to go” and, “Staff did not tell us about the [medical] appointment (so that we could support him). They needed to tell us so that we can go with him. They do not follow up, so we do not know if they have made another appointment."

Staff told us there was information in people’s care plans to promote people successfully accessing healthcare services. This included information around people’s communication and behaviour. Senior staff told us that the provider was committed to ensuring people had access to healthcare. This included flexibility around staffing to accompany people to appointments or support them whilst in hospital.

We received feedback from the local authority that they had offered support to the provider after concerns had been raised around the quality of care. They told us they had received multiple concerns around incidents that had occurred, included some relating to accessing healthcare services. They told us that at the time of the assessment this support was still ongoing.

People had resources in place to help promote their access to health services. For example, each person had a hospital passport. This is a document taken to appointments to help give health and medical professionals an overview of people’s communication and behavioural needs. However, staff did not always plan appointments effectively to maximise the chances of people successfully attending. They did not always fully consider the steps needed to minimise people’s anxieties around these events. This had resulted in incidents when attending appointments, which meant people did not always receive the professional input they required.

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to relatives about their family member’s experiences of receiving support and care. We also spoke with an advocate, who had recent experience of working with people. Relatives raised concerns about the safety of their family members at the service. Concerns included, how incidents were managed by staff, lack of documentation surrounding incidents, the provider not acting upon concerns raised, not always being involved in best interest’s meetings about people’s care. Comments included, “My heart sinks when I have to visit the care home because of the poor reporting in the care plans”, “[My relative] is not safe. No action plan received of what management are doing to address my concerns”, “A Best interest meeting [was] held, but the staff did not invite me. When I asked, they stated that they did not have my details. I should have been there and did not receive any minutes or any follow up action plan” and, “Atmosphere is clinical. Would certainly not recommend this place to others."

There was mixed feedback from staff around the training they had received in safeguarding and The Mental Capacity Act 2005 (MCA). Staff we spoke to were knowledgeable about recognising the signs of abuse and the appropriate reporting of concerns. However, some staff did not have an awareness of the MCA. This was significant as the MCA is the legal framework that protects and empowers people who lack the capacity to make decisions about their care and treatment, which was relevant to the people living at the service. The area manager told us they would be focusing on improving staff’s knowledge around the MCA through additional training and discussions in staff meetings.

We made assessment site visits to the service on 4 separate occasions during different times of the day. We observed a range of staff providing support to people in communal areas of the home. We observed that access to the kitchen and between different floors of the home was restricted by a key lock, which people were not able to operate independently. This meant that they relied on asking staff to access different areas of their home. We brought this to the attention of the area manager, who agreed to review these restrictions as they acknowledged that they may not be the least restrictive arrangement available.

The processes to record, report and analyse incidents was ineffective in safeguarding people from coming to harm or reducing the risk of reoccurrence. Staff told us about specific incidents that had taken place at the service. However, when we checked the provider’s records there was no information or limited associated records around these incidents. Therefore, it was not clear how the provider had followed these up to safeguard people. In another example, during our assessment, the local authority made us aware of a choking incident at the service. The area manager confirmed they were not aware of this incident as there was no record of it on the provider’s incident logs. This demonstrated that the system to ensure incidents were recorded and responded too appropriately had failed. The provider had an internal support team, who had identified and reduced some restrictions to people. However, they had not identified the restrictions around access to the kitchen and between different floors of the service highlighted during our assessment’

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to relatives about their family member’s experiences of receiving support and care. We also spoke with an advocate, who had recent experience of working with people. Relatives raised concerns about how risk related to their family members medical conditions were managed by staff. They commented, “[My relative] had a [seizure] a couple of months ago and staff did not know what to do.” Relatives felt that some staff were not confident in supporting people around their complex needs and behaviour. They felt this had a negative effect on people’s experience when accessing the community, due to incidents that had occurred. Comments included, “[My relative] is challenging in the transport. [My relative] needs the right relationships and not strangers around."

Some staff told us that there was not enough information in people’s care plans to effectively manage risks. For example, for one person, staff felt there was not sufficiently detailed guidance around supporting the person with their behaviour. They told us that other less experienced staff struggled to support people to remain calm and deescalate their anxieties, which had contributed to a number of incidents escalating. Staff who had worked with people for some time told us they felt confident working with people as they had taken the time to build a trusting relationship. They told us this was key in supporting people to manage risks.

We made assessment site visits to the service on 4 separate occasions during different times of the day. We observed a range of staff providing support to people in communal areas of the home. We observed an inconsistent approach from staff when supporting people. Some staff were calm, pro-active and confident in their approach. They understand what people were communicating through their behaviour and responded accordingly. However, other staff did not appear engaged with people, motivated in their role or confident in meeting people’s complex needs. There were examples where staff were adopting strategies not in line with people’s care plans. This put people and other staff at risk as people required a consistent approach to remain calm.

People had care plans and risk assessments in place around their safety, medical conditions and behaviour. However, care plans were not always detailed and did not contain comprehensive information about how staff could reduce risks. Some people’s care plans contained out of date information. In one example, one person’s care plan detailed how they lived at an alternative care setting. This meant that that risk assessments did not always reflect risks related to the care home environment. People had positive behaviour support plans in place which identified approaches staff should follow when supporting people and what people may be communicating through their behaviour. This guidance gave staff guidance to follow in order to adopt a consistent approach when supporting people.

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to 5 relatives about their family member’s experiences of receiving support and care. We also spoke to an advocate, who had recent experience working with 2 people living at the service. The majority of relatives were positive about the safety of the care home environment. They told us the provider had made improvements around the security of the garden and general refurbishment. One relative was positive about how their family member had new reinforced flooring fitted in their room as they frequently jumped heavily on the floorboards. However, one relative felt that their family member would benefit from moving to a downstairs room due to accessibility issues. We brought to the attention of the provider to address.

Staff told us that they had received training in emergency evacuation procedures. This included simulated evacuations of the building to help ensure they were familiar with procedures. However, some staff told us they needed more training on the use of emergency evacuation equipment to increase their confidence in its use.

We made assessment site visits to the service on 4 separate occasions during different times of the day. We made observations of the service environment in relation to the safety of the premises. We observed some positive aspects around the cleanliness of the service. However, we observed issues relating to fire and water safety, which we asked the provider to address. For example, the boiler room was being used for the storage for combustible items. This posed an increased fire risk as the items were a source of ignition. In another example, an unoccupied bedroom was being used for storage. This made accessing the en-suite to complete water safety checks difficult due to the items obstructing the area. The fire assembly point was in the back garden. This was only accessible from the front of the property via a code locked gate. This made it difficult to access in the event the event of an evacuation if people’s exit route was via the front of the service. The area manager told us they would be replacing the coded lock to make the assembly point easier to access in an emergency.

The provider had not fully implemented actions in line with external professionals recommendations around water and fire safety. For example, an external company completed a legionella risk assessment in August 2023. The provider had not completed all water safety monitoring checks as recommended. An external company had completed a fire risk assessment of the service. Their report highlighted actions around storage of combustible items, fire doors and training for night staff. At the time of our assessment, these actions had not been fully addressed. This put people at increased risk of coming to harm.

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to 5 relatives about their family member’s experiences of receiving support and care. We also spoke to an advocate, who had recent experience working with 2 people living at the service. Relatives told us that there was a high turnover in staff, which resulted in an inconsistent approach to supporting people. One relative commented, “They need more regular, full time permanent staff to understand the residents.” Although relatives did say some staff were caring and worked well with people, they told us there were a number of staff who were not motivated, committed or effective in their role. Comments included, “Staff are non-plus and no interest in the residents”, “Staff are just being lazy” and, “With some staff it feels like they do not want to be there and they are not engaging.” Relatives felt there was a closed staffing culture at the service, with cliques in the group that did not promote a positive and open atmosphere at the service. One relative told us, “[There is a] high turnover of staff with a closed culture and they do not really care."

Staff told us there were not always enough staff on shift to support people safely. They commented that some staff were not motivated or suitably skilled for their role. They told us this made them feel sad as it undermined the efforts of the staff that genuinely cared about people and wanted to provide good quality care. Most staff felt the supervisions they had with the previous manager were useful and supportive of their role.

We made assessment site visits to the service on 4 separate occasions during different times of the day. We observed a range of staff providing support to people in communal areas of the home. We observed a mixed quality of interaction and support between staff and people. However, we observed that there were adequate numbers of staff in place, which was in line with people’s commissioned care.

The provider did not have robust staff recruitment processes in place. We reviewed 3 staff recruitment files and found gaps in recruitment information including, references from previous jobs in health and social care, verification of reasons for leaving previous employment, evidence that up to date right to work information had been verified, missing application forms, missing health questionnaires. This meant that the provider had not fully assessed these staff’s skills, experience or suitability to work with people. The provider’s recruitment policy did not fully reflect the guidance set out in statutory regulation. We asked the provider to review this policy. The provider had limited overview of staff’s ongoing training needs. There was limited evidence about how staff’s ongoing training and development needs were monitored and assessed. The provider had a policy document detailing the intervals in which staff training should be updated. However, intervals between training updates did not always reflect current best practice guidance. This included safeguarding, basic life support, The Mental Capacity Act 2005, fire safety and positive behaviour support. Many subjects not refreshed annually and there was no evidence of an annual knowledge check. This meant we had limited assurance about how staff’s ongoing training and development needs were monitored and assessed.

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to 5 relatives about their family member’s experiences of receiving support and care. We also spoke to an advocate, who had recent experience working with 2 people living at the service. Relatives told us they had no concerns around infection control, cleanliness or hygiene at the service. Comments included, “[The service] is clean."

Staff had a good knowledge of how to use personal protective equipment (PPE) appropriately. Senior staff told us they made direct observations of staff to help ensure they were following good infection control practice.

We made assessment site visits to the service on 4 separate occasions during different times of the day. We made observations of the cleanliness and effectiveness of the infection control practices at the service. We did not observe any practice of concern during our visits, the service was clean and hygienic.

The provider had an appropriate infection prevention and control policy in place. The provider had processes in place to ensure staff had access to personal protective equipment to carry out their role.

People were unable to give us verbal feedback about their care. Therefore, where appropriate, we spoke to 5 relatives about their family member’s experiences of receiving support and care. We also spoke to an advocate, who had recent experience working with 2 people living at the service. Relatives gave positive feedback around the support people received in managing their medicines. There was positive feedback around storage of medicines, availability of rescue medicines and people receiving their medicines on time. Comments included, “Medication in locked cabinet. Staff give it to him at 12 noon with beaker of water. They watch him swallow it."

We were not assured that all staff were trained, and their competency assessed in the safe administration of medicines. Staff told us that the training they received in medicines administration was not detailed enough to meet people’s needs. They said they received limited support in improving their confidence and knowledge through management support or competency assessments. At the time of our assessment the deputy manager was solely in charge of overseeing medicines at the service. Therefore, there was little contingency in place should the deputy manager be absent from the service. This increased the risks associate with the ordering, storage, administration and returning of medicines.

Systems and processes to ensure that people received medicines safely were not effective. The providers governance processes did not always mitigate risk, identify issues and promote learning from medicines related incidents. There had been a significant number of medicines errors that had occurred. This included people not receiving their medicines as prescribed, through late administration or missed doses. There was no evidence of shared learning from these incidents, to prevent reoccurrence. This put people at increased risk of coming to harm. The provider carried out audits of medicines management systems. However, the audits failed to identify concerns related to medicines management found during this assessment. Care plans for medicines were not always person-centred and did not contain sufficient guidance for staff to follow about how to monitor and manage people’s medical conditions. For example, one person had a lifelong condition that required medicines to be administered at specific times. Their care plans lacked information around the importance of administration times to manage acute exacerbations. Where people were prescribed ‘when required’ (PRN) medicines, care plans did not always contain enough information to support staff in administering consistently, as intended. For example, how someone may express that they were in pain. Risks related to medicines were not fully assessed. For example, there was no assessment in place for increased fire risk related to the use of emollient based creams. This put people at increased risk.