Ruth 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

At our last inspection we rated this key question requires improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulations in relation to people’s safe care and treatment, people being protected from the risk abuse and neglect, staff training and deployment and the recruitment processes for staff. The principles of RSRCRC were not met as the model of care provided did not allow people to live empowered lives with maximum choice. The risks associated with people’s care were not always being managed in a safe way and there was not always sufficiently qualified and trained staff to support people in a safe way. The recruitment of staff was not undertaken appropriately. People’s medicines were not always being managed in a safe way. People were not protected from the risk of abuse. Incidents were not being reported or investigated to reduce risk of reoccurrence.

This service scored 28 (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 failed to ensure there was a proactive and positive culture of safety based on openness and honesty. Incidents were not always recorded in detail or analysed to look for trends. This meant there was little opportunity for lessons to be learned when things went wrong. The provider told us all incidents of distressed behaviour were recorded on behaviour charts and that they had debriefs with staff to discuss where things could be improved. However, there was no evidence of the debriefs with staff and the incident reports lacked detail on what preceded the incident that led to the anxiety. Staff were not always recording incidents. We found references in people’s care notes to 1 person having frequent high levels of anxiety, yet these had not always been recorded as an incident. There was no analysis of the incidents to look for trends, themes and triggers to try and reduce the risk of incidents which placed people at risk.

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.

People were not protected from the risk of abuse and neglect. Staff had received safeguarding training, but they were not always recognising or reporting abuse. Whilst we did not receive any direct feedback from people or their relatives, we saw from care notes 1 person had been subjected to verbal abuse from another person. Staff were not always completing an incident form and had not reported these as safeguarding concerns. The provider failed to ensure people were protected from unlawful restraint. Staff told us 1 person was routinely being restrained when the person was hitting out at staff. The provider had not provided any training to staff on how to safely restrain and the local authority had not approved this restrictive practice. We have reported this to the local authority. Where other incidents indicated a safeguarding concern, these had not been reported to the local authority as required.

The risks associated with people’s care was not managed in a safe way. One relative had fed back to the provider their concern over the lack of monitoring of their family members nail care. We found where staff were cutting people’s nails there were no risk assessments in place and staff had not been competency assessed to ensure they did this in a safe way. We saw from a staff communication book that in August 2024 a dentist had identified a hole in 1 person’s tooth. It was recorded that staff were to monitor this however staff we spoke with were not aware of this. The person’s care plan had not been updated with this information. This meant there was a risk they would not pick up on the deterioration. Leaders had not routinely reviewed risk assessments which meant the information may not have been up to date or accurate. We saw from their care record staff were required to place a slip mat in the bath when people had a bath. However, we observed there was no slip mat and staff told us they did not use one. This placed people at risk of slips and falls as 1 person routinely had a bath. The Behaviour Support plans in place for people did not have sufficient guidance for staff on how to support service users when they were in a heightened state of anxiety. There was a lack of information on what may trigger people or how staff needed to respond when the person was directing their anxiety towards people, staff and others. There was no evidence the provider had sought input from professionals to support the guidance in the ‘Behaviour Support’ plans.

The provider had failed to ensure the environment and equipment had been set up to ensure people’s safety. There was lack of radiator covers in the communal spaces and the radiators were very hot to touch risking people burning themselves. The provider had raised this as an issue in an October 2024 audit yet took no action to address this or included risk assessments in people’s care plans around this. There was a free-standing tall cabinet in 1 person’s room that was not fixed to the wall and there was a risk this would fall on people. The screws on the curtain rails in the lounge and 1 person’s bedroom were hanging out and there was a risk the curtain rail would fall on a person. The garden fence was being held up by 2 planks of wood and there was a risk this would fall on people who staff said enjoyed spending time in the garden. There were large paving stones in the garden that were loose and wobbled when walked on risking injury to people. The provider failed to ensure service users are safe in the event of a fire. We saw there had been a fire safety report from September 2024 where multiple areas of concern were identified yet the provider had not taken action.

There were not sufficient staff deployed to manage people’s needs in a safe way. Leaders told us a member of waking staff was required to support people at night due to the risks posed to people. However, they and staff confirmed that staff were routinely sleeping at night but setting their alarms to wake up to check on people. This placed people at risk of harm if staff were not awake and people needed them. We asked the provider to urgently address this. Staff had not received appropriate training in relation to their role. We saw from the training matrix that not all staff had received training in moving and handling, autism, learning disability, first aid and communication. The provider told us they were not familiar with the guidance on RCRSRC and told us staff had not received training around this. This meant leaders could not be assured staff were providing the most appropriate care. There was a lack of evidence staff were receiving one to one supervisions despite the service policy stating these needed to be undertaken frequently. The provider did not operate effective and safe recruitment practices when employing new staff. Of the 2 staff files we looked, neither had a full employment history and their references did not match the details of the previous employer of the member of staff. This meant the provider could not assured of the staff suitability to work at the service.

The provider failed to ensure people were protected from the risk of infections. Although staff told us they received infection control training, there were shortfalls in the cleanliness of the service. We observed 1 person’s pillow was heavily stained and the bottom sheet of their bed had been left to dry in a garage amongst debris, metal and old furnishings. The fabric on 1 person’s chair was torn with foam exposed which would have made it difficult to clean. Cupboards in the kitchen were stained and dirty and the freezer seal was torn meaning cleaning would not be effective. In the downstairs bathroom, which staff told us was dedicated for them to use, neither tap on the sink were working as both handles had broken. This meant staff could not wash their hands before leaving the bathroom. We saw staff disposed of 1 person’s used continence aids in a bin in the garden. However, the bin lid was not secured and could be accessed by people which was an infection control risk. Infection control audits were taking place, but they were not identifying the concerns we found.

The provider failed to ensure the administration of medicines was managed in a safe way. We saw from their handwritten Medicine Administration Record (MAR) staff had not signed or countersigned by a second member of staff to ensure its accuracy. This meant there was a risk people would not be administered medicines correctly. Not all staff administering medicines had been competency assessed to do so. The provider told us they were behind with doing the assessments. This meant they could not be assured all staff were safely administering medicines which placed people at risk. We saw from 1 person’s ‘as and when’ guidance for pain relief, 2 tablets could be given to the person every 6 hours. However, the guidance later says the person was not to be given more than 8 tablets in 24 hours which would have been two tablets every 4 hours and not 6. This meant there was a risk staff could wait longer than was necessary to give the person pain relief. The guidance stated this guidance needed to be reviewed every six months or earlier however this had not been reviewed since December 2023. There were other areas of the management of medicine that were safe. There were no gaps on the MAR and the counts of medicines for people were correct.