Rocklee Residential Home Limited

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to safe care and treatment of people at the service.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People said they felt safe living in the home, and they told us they could raise concerns easily. One person told us, “There are forms by the front door with pictures on. We can use these if we want to complain. If I am not happy, I can contact the registered manager or the deputy manager.”

Staff told us lessons learnt from incidents and accidents were shared in team meetings. One staff member said, “Incidents are shared with the team through staff meetings as well as handovers. Incidents can also be found in the incident book which can be easily accessed.” However, actions identified by visiting professionals carrying out quality audits or fire risk assessments were not always completed in a timely manner.

Incidents involving people were analysed and lessons learnt were shared with the staff team. However, actions identified from external audits were not always acted upon. For example, 1 action from a fire risk assessment was not completed despite the visit taking place the previous year. The registered manager completed this action during this assessment and a new fire risk assessment was carried out by a visiting professional.

People told us they had the opportunity to engage in meetings with staff to review their goals and discuss how these were going to be achieved.

Staff told us they had the opportunity to read care plans and identify risks. One staff member said, “When a new person moves into the home, we are able to read the care plan and the referral assessment to see what care they require.” We reviewed risk analysis with members of the management team. Care plans and risk assessments did not always identify the risks posed to the person or set out clear instruction for staff to take to mitigate the risk or escalate concerns. The registered manager explained they were in the process of reviewing care plans and risk assessments.

Visiting professionals told us the provider worked with them to review the care and support people received. However, they also told us the provider was sometimes slow to act on their recommendations and implement the identified actions.

Care plans and risk assessments were in place to address risks to people within the home and the community. However, these did not always identify strategies for staff to support people with their health conditions or behaviours. Where people required support with personal care, care plans contained conflicting information and risk assessments did not detail the support required from staff or the number of staff needed.

People said staff supported them safely, and they told us they were confident to raise concerns with members of the management team.

Staff told us they received safeguarding training. One staff member said, “I have received safeguarding training. I learnt policies and procedures have to be followed to ensure safe care and to ensure that everyone is protected.”

We observed staff supporting people safely. Where people required support, staff attended to them quickly and professionally.

The provider raised safeguarding concerns with the local authority when required. However, the provider’s safeguarding policy was outdated and did not reflect current policy or best practice. The provider responded to our feedback by updating the policy.

People told us staff encouraged them to make safe choices but ultimately respected their decisions. One person said, “Staff tell me if it’s cold or icy outside. They tell me to be careful and dress warmly, but it’s up to me.”

Staff told us they promoted people’s choices and respected their wishes. One staff member told us about people accessing the community independently and making choices such as visiting local pubs and restaurants. However, where 1 person chose to vape, there were restrictions in place. We discussed these restrictions with the management team, who informed us the person agreed to this intervention to reduce their addiction to nicotine. However, this decision was not clearly documented as the person’s choice.

We observed people leaving the home independently to access the community and returning when they wanted. People chose what they wanted to eat and drink, and staff respected their decisions. However, where restrictions were in place, records did not always document the rationale or past discussions with the person concerned.

Care plans and risk assessments did not always record people’s choices and decisions. Where 1 person chose to receive support with their personal care on set days with support from a specific gender of staff, this was not documented in the care plan or risk assessment. This is important to reflect people are living free from restriction and are empowered to make their own choices, including unwise decisions.

People told us they lived in a well-maintained home. One person said, “I think it is clean here. The home is being re-decorated, and the garden is being changed. It'll look nice when it's completed.”

Staff told us they took part in regular fire safety tests, such as fire alarm and evacuation tests. However, when we requested people’s PEEPs (Personal emergency evacuation plans), only 1 was available. The registered manager informed us these had been completed but was unable to locate them. A PEEP is a plan for a person who may need assistance to evacuate a building or reach a place of safety in the event of an emergency such as a fire. These should be in place for each person and easily accessible for staff. The registered manager later shared these with us and told us they were being stored in an accessible place.

We observed building work and decoration taking place. The provider shared their plans for the building and garden areas. The provider shared their emergency business continuity policy which recorded locations of emergency stop taps of energy supplies, for example water and electric. However, this had not been completed and there were blank sections in the policy. This meant the provider could not be assured staff knew how to turn off energy sources in case of emergency. The registered manager completed the policy and shared this with the staff team.

Health and safety checks were taking place. However, whilst water temperatures were being taken, on occasions the readings exceeded the maximum safe temperature limit to prevent potential scalds. The registered manager explained temperature limiters were set on showers, but these needed to be fitted to sinks and the bath. A date was arranged for these to be fitted, and steps taken to mitigate the risk to people whilst waiting for the contractor to fit the temperature limiters.

People told us there were enough staff on duty to support them safely. One person said, “I think there are enough staff. The staff are there to help us.”

Staff told us there were enough staff on duty to support people. One staff member said, “We have always got enough staff on duty, some days are not as strong as others. If people have appointments, we get extra staff.” However, when we requested the past staffing rotas. The registered manager explained past rotas were not retained. A white board displaying the rota for the current month was wiped clean at the end of each month. There were staffing timesheets to record which staff member worked each day, although this made it difficult to review the numbers, skill and gender mix of the staff deployed throughout the month.

We observed staff supporting people in a timely and professional manner. We observed the staffing rota on the wall. However, this was not always reflective of the staff on duty.

The provider was not retaining rotas. Staffing rotas are required to evidence the deployment of suitably qualified, numbers and types of staff on duty. On request the provider completed past rotas based on timesheets. The rotas shared were not always in accordance with people’s needs or choices. For example, 1 person requested a specific gender of staff to support with personal care on set days. However, there were days when the rota displayed an absence of this gender of staff. Other days displayed family members working alone together which contrasted with the provider’s risk assessment. This meant the provider could not be assured there were enough staff deployed to meet people’s needs.

People told us they lived in a clean home. One person said, “Staff clean the home. They [staff] encourage us to keep our bedrooms tidy and clean.”

Staff told us they used personal protective equipment safely (PPE). One staff member said, “We have more than enough PPE. All staff have received infection prevention control training.”

The home smelt fresh and looked clean and presentable. We observed staff carrying out cleaning tasks.

The provider carried out infection prevention control audits, and all staff received infection prevention control training.

People told us their medicines were stored safely. One person said, “Staff keep the medicines in the cupboard. They [staff] help me to take my medicines.”

Staff told us they received safe handling of medicine training, and their competencies were regularly refreshed. One staff member said, “The provider checks staff competencies. The pharmacy sometimes comes in to talk with us [staff] and to provide updates if needed.”

Medicines were stored safely. However, where 1 person required their medicines administered once a week, the medicine administration record (MAR) recorded this had been administered each day. The registered manager explained this was an oversight, explaining only 4 of these medicines had been received from the pharmacy each month. Although, this meant the provider could not be assured staff understood why they were signing the MAR record. Another person’s care plan recorded they were in receipt of a medicine which was not being administered. The registered manager responded to our feedback by reviewing MAR records with staff and removing the medicine from the care plan.