The Radcliffe

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

The service was not always safe. Some risks to people were not managed or planned for effectively. Action was not always taken after incidents to reduce the risk of recurrence. Medicines were not always managed and administered safely. Staffing levels at night were not always safe or sufficient to meet people's needs. The environment was not always safe. We found evidence the service was in breach of 2 regulations around management of risk, medicines and staffing. Despite our findings, people told us they felt safe and had their needs met. There was a safeguarding policy in place which staff were aware of and followed. Incidents had been reported to safeguarding where appropriate. We fed back our concerns to the management team after our first inspection visit, and they took prompt action. On our second inspection visit, we found improvements had been made.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received feedback from 9 people and 4 relatives. In our conversations with people and relatives, several told us falls had occurred. We received mixed feedback from relatives about the quality of the changes to care arrangements after a fall. Comments included, "[Person] has had about three falls. They have now put bed sides on" and "[Person] has had lots of unwitnessed falls. The system buzzer had not worked so I have lost trust. The pressure mat was off."

Staff confirmed that they had received training via e-learning and had undertaken shadow shifts prior to commencing support. There was not a system in place nor a culture of learning from incidents to improve care.

During this assessment we found there was a lack of effective learning from accidents and incidents. Accidents log shows most falls were unwitnessed and happening during the night shift. The incidents were recorded and analysed every month, however, this information had not been used to review staffing levels or people's care arrangements around falls. We discussed our concerns with the registered manager and on day 2 of our assessment, we were informed that a 3rd member of staff would be on night shifts to reduce risks. After our assessment. We reviewed evidence confirming that the registered manager had taken action and care for people who were at risk of falls had been reviewed.

Most people and relatives told us they felt safe living at the service. People's comments included, "I have no worries here and everything is ok" and "I feel safe here because the people here that look after me are professional." Relative's comments included, "[Person] is safe here and [they] love it here."

We did not collect any evidence to report on in this area.

Partners did not raise concerns about the process of admission of new residents or transitions. However, the home had been under enhanced contract monitoring due to concerns identified by the local authority contracts team and also the infection control team in relation to safety and management of the service. After our inspection, the provider decided to suspend any new admissions to focus on improvements.

Initial assessments were not documented to show needs and preferences had been assessed before admission to the home. The registered manager told us they would review the assessment completed by the social worker, gathered information from the person or relatives remotely but would not always complete a visit to assess person's needs. During this inspection, we found lack of evidence of initial assessments being completed and we also found a lack of risk assessment and care planning for people living at the home.

People told us they felt safe. Comments from people included, "I am safe and happy" and "Yes, I am safe here." However, one person raised concerns about their finances and belongings being taken by another resident. We discussed these issues with the registered manager and we were assured these matters were known and were being acted upon. Most relatives told us they felt their family member was safe with the care provided. However, one relative raised concerns about the care of their loved one. In our conversations with staff and the registered manager we confirmed appropriate action was being taken to ensure the person was safe and receiving the care required.

Staff told us that they felt the service was safe and that they had received training prior to supporting people. Staff told us that they could not hear call bells when in peoples rooms and night staff confirmed that they used their personal mobile phones to contact each other during the night. Two people required two staff members to move. When this was being undertaken during the night, the staff members would be unable to hear call bells in the building which would leave people unsafe.

We observed that staff supporting people safely. However, upon our arrival, the small kitchen area had no staff present and people were left unsupported where there was potential for harm from boiling water and clutter.

There was a safeguarding policy in place and this was being followed. The registered manager was aware of their responsibilities under safeguarding. When incidents of abuse or neglect had occurred, these were appropriately reported to the local authority safeguarding team and to CQC.

People told us they felt safe. Comments from people included, "I feel safe because I can do what I want." Most relatives told us they felt their family member was safe with the care provided. However, one relative raised concerns about the care of their loved one. In our conversations with staff and the registered manager we confirmed appropriate action was being taken to ensure the person was safe and receiving the care required.

Staff told us that people were not always involved in the implementation of their care plan upon initial assessment or review. Care plans and risk assessments were on handheld devices, with there being no evidence of these being printed out for people to have their own copy should they wish.

Our observations raised no concerns regarding involving and managing risk at the service.

Risks to people's care were not well managed. There were a lack of risk assessments in place and a lack of care planning. Some people were at known risk of developing pressure ulcers but there was either not a care plan in place detailing the care people required, or the one in place lacked detail. The manager indicated that all residents should be checked and repositioned every 2 hours. We reviewed the care records and there was no evidence that these people were being supported every 2 hours. The manager told us they would complete regular checks on repositioning to ensure this task was being completed. The provider also updated us after the visit and stated risk assessments had been updated. Several people were at risk of falls. Some people who had fallen did not have a falls care plan in place. The manager told us they were in the process of sending a referrals to the falls team for 2 people and would review the others too. After our visits, the provider updated us on the actions they had taken or were taking to address the concerns we discussed with them in relation to how these risks are being managed for all the other residents at risk of falls and if other crash mats have been put in place. Despite actions taken after the inspection, we remain concerned that the provider was unable to identify these issues independently and take action to protect people from harm. This forms part of the breach in Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Despite our concerns about the environment, people told us the environment was safe and clean. Comments included, "My room is nice and clean and I clean it myself as well" and "Oh yes, it is clean." A relative told us, "It is clean but only basic."

Staff were unaware of which people had airflow mattresses in place. No clear information was given to staff members regarding the appropriate setting of these mattresses. The settings on pressure mattresses are important as they control how effective the mattress is in relieving pressure. Staff were also unaware of which people had bed rails in place and some said no one did. When we checked, we found that three people had these in place.

One person asked to sit outside but a staff member was unaware of the code to open the door. The service had some areas that require maintenance and redecoration to promote people's dignity and respect. Two toilets were out of use which impacted on people being able to access the toilet quickly. The floor was uneven at the top of a staircase which placed people at risk of falling. Window restrictors were missing throughout the building and some were broken. Some were inappropriate, with a chain being used instead of a proper window restrictor.

We found some concerns about the safety of the environment in relation to staircases, the risk of falls, fire safety, window restrictors and cleanliness. There was a lack of risk assessments in place. There were several people at risk of falls and there were several staircases in both units. People were observed to walk without supervision of staff. Call bell reports showed several people who were at risk of falls and with sensor mats in place were waiting long periods of time for staff to respond. We asked, but did not see, an environmental risk assessment in place to consider how risks of people falling on the stairs was managed. After our visits, the provider told us they had created specific environmental risk assessments relating to the staircases and stair lift. However, at our second visit we observed a fire escape route being blocked by equipment. We also found some windows without restrictors or risk assessment. Although action was taken after we raised concerns, we could not be assured action would have been taken without us identifying these issues for the provider. This forms part of the breach in Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Feedback about staffing was mixed. People told us, "When I ring my bell they come very quickly. I think there is enough staff" and "I think there are enough staff in this unit." A relative said, "The amount of senior staff is inadequate. There is enough staff but they could do with more seniors." Another told us, "Seems enough staff on a weekend."

Through the night only 2 staff members were on duty. The communication between them was via their personal mobile phones and staff told us that when in bedrooms supporting people, they were unable to hear the call bells of other people, including emergency bells. This placed other people at risk of not receiving support when they need it or in an emergency.

During the day there were many times where we observed no staff present in communal areas. We observed one resident telling another to sit down as they would fall. There were no staff members around to redirect the person and ensure they were safe. Staffing in the afternoon improved. At morning handover, we observed one staff member went into handover whilst the other stayed on the unit. When speaking to the housekeeper, they stated that if the handover runs over and the night staff go home, they manage the floor and “get people anything they need for breakfast etc." This did not assure us there were sufficient staff to meet people's needs at all times. Recruitment was mainly managed safely. There was a recruitment policy in place and this was being followed.

We found concerns in relation to staff numbers and staff deployment. During day 1 we observed call bells were not responded to in a timely way. The manager told us they expected staff to respond to people within 5 minutes, however, there were several examples of people waiting over 10 minutes. This included when sensor mats were alerting staff that people at risk of falls were mobilising independently. We reviewed the call bell response time's report and this showed several people waiting over 10 minutes regularly. We were shown evidence that the provider was implementing a call bell audit after our inspection. The accidents log shows most falls are unwitnessed and happening during the night shift. However this pattern had not been identified by the provider and no actions had been take to review the staffing levels at night accordingly. We raised our concerns with the provider and they informed us that an additional member of staff would be placed on night shifts to ensure people were responded to more promptly. The provider used a dependency tool to calculate the number of staff required to meet people's needs. However, we found evidence that this was not an accurate reflection of people’s needs and the tool used did not take into consideration the layout of the building. Although action was taken after we raised concerns, we were not assured the provider was capable of independently identifying these issues and taking action to protect people from harm.

People told us the environment was clean. Comments included, "My room is nice and clean and I clean it myself as well" and "Oh yes, it is clean." A relative told us, "It is clean, but only basic."

Our discussions with staff raised no concerns about infection prevention or control practices.

Some areas of the building required cleaning and redecoration to promote people's dignity and respect. We saw personal protection equipment (PPE) was available throughout the home. PPE forms a protective barrier to reduce the spread of infection. Other areas of the building, such as the kitchen, were observed to be clean throughout. Further work was required to ensure the service was consistently clean and well maintained in all areas.

We found some areas of the home were not clean. There was a regular team conducting domestic work. The manager was not documenting their regular checks and walkarounds, and these were not effective in identifying the issues we found. Infection Prevention and Control audits had been completed and feedback had been provided by the local infection control team in areas that required improvement, but these still needed to be acted upon. After our inspection, the nominated individual told us regular walkarounds were now taking place with infection control areas being looked at. People and relatives did not raise concerns in this area.

People shared mixed feedback about how their medicines were managed, including some concerns about their medicines which we followed up during our assessments. People's comments included, "I don’t discuss anything about my care with them or my medication. I like to just leave it to them." Another person said, "I feel safe. I do have occasional medication." One other person raised concerns and said, "I am missing my medication. The doctor has not sent my prescription."

Medicines were not always safely managed. Senior staff who were administering the medication were not knowledgeable about best practice guidance in administering medicines in care homes. Senior staff did not ask people if they were ready for their medication before starting to dispense it. Senior staff did not know that some creams needed to be stored in the fridge to maintain their integrity. Senior staff had not received an assessment of their competency in administering medicines for over a year. After our inspection, we received evidence of medicines competencies being completed for staff. Medicines audits completed by the registered manager had not identified the issues found during this inspection. Although action was taken after we raised concerns, we could not be assured action would have been taken if we had not made the provider aware of these shortfalls. This forms part of the breach in Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicines were not always managed safely. Medicines was not stored at the correct temperature. This included medicines which required refrigeration. No checks were undertaken of the temperature of medicines storage areas. Medicines stored at temperatures too high may degrade and become less effective, placing people at risk. On our second visit, we found improvements in one unit, but on another unit the fridge temperature was still too high. After our second visit the provider showed us evidence that daily checks were now being carried out of fridge and medication trolley temperatures. On our first visit we found that prescription creams which needed to be refrigerated had been stored in people’s bedrooms in unlocked cupboards. All creams with a prescription label should be securely stored. The registered manager took immediate action when we raised this with them but had not independently identified this issue. However, their action was ineffective as at our second visit we still found prescription creams were not stored appropriately. Medicines prescribed ‘as and when required’ (PRN) were not managed well. Protocols were not in place setting out when and why these medicines should be administered and at what frequency. Some people had received PRN medicines every day for a month with there being no explanation as to why. This included controlled drugs. Reviews of people’s medications were not taking place. After we raised these issues, the provider gave us evidence that they had now put in place the PRN protocols and had a senior member of staff overseeing the administration of PRN medicines. However, we remain concerned that the provider or registered manager failed to independently identify these issues. This formed part of the breach of Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.