Redwood House

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 identified 2 breaches of the legal regulations. Risks to people’s health, safety, and well-being were not always well managed, and people did not always receive their medicines safely. Some areas of the home were not safe and well maintained. However, staff felt supported, and team meetings took place. The provider worked with external professionals appropriately. Staff had received safeguarding training and knew how to report abuse. People told us they felt safe. There were effective systems to manage complaints.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People could raise concerns, complaints, and compliments. The provider had also produced an easy-to-read complaints policy to support people in raising any concerns they had. A person told us they saw the registered manager almost daily and felt they could always speak to them if they had any problems. A relative confirmed, “I am informed of any issues.”

Staff told us learning from incidents and accidents were discussed during handovers and team meetings.

The provider identified themes and trends from incidents and accidents people had experienced. This resulted in changes to people’s care plans. For example, one person’s care plan had been updated to reflect that staff should no longer prompt the person to wake up in the morning, to prevent them experiencing emotional distress. Learning from incidents was discussed in team meetings.

External health professionals had been involved where needed. For example, 1 person had received support from a physiotherapist with their mobility needs. This had resulted in mobility equipment being provided to promote their safety. One person told us they had recently seen the doctor and dentist.

There was not always a good awareness of the steps that could be taken to reduce risks people could experience. For example, when we asked why wardrobes were not secured to walls, the registered manager said no one was at risk from this. However, we later found that a person held on to furniture as they walked and were at greater risk of falls. This meant they would be at increased risk of pulling furniture on top of themselves. The registered manager arranged for their furniture to be secured after we highlighted this concern.

There were shortfalls in the provider operating effective systems to ensure people's safety was always assessed and monitored. This included safety concerns with people's medicines, staff being trained to meet people's health needs, and safety of the environment. Although actions were taken or planned to improve people's safety, this resulted from our identifying concerns during this assessment.

People did not raise any concerns in relation to safeguarding. 3 people we spoke with confirmed they were safe and happy living at Redwood House.

Staff were able to tell us how they would report safeguarding concerns if they needed to. This included contacting company directors or the local authority safeguarding team.

We observed staff interacted with people kindly and respectfully during our visits to Redwood House.

There were increased risks to people who could not manage their money independently. People had transactions recorded without receipts. Where it was impossible to obtain receipts, staff were not always descriptive enough about what people's money had been spent on. Better financial recording for people's expenditures proactively safeguards people from the risk of financial abuse. However, information was available and displayed to signpost staff and visitors about who they could contact with any safeguarding concerns. Staff had received safeguarding training. The provider had appropriately sought authorisation to deprive people of their liberty where required.

People told us they felt safe and were supported to attend health appointments. Where people were known to communicate emotional distress, staff could support them with care plans that were person-centred and reflective of learning from people's previous experiences.

Staff described how they involved people to manage risks and promote independence. For example, a staff member told us that due to a person’s mobility needs, they walked with them to shower and carried their toiletries but did not walk with them at other times as they could manage on their own.

Environmental safety, individual health risks, and medicines were not always well managed, increasing health and safety risks to people. This is covered in more detail in other parts of the report. However, we also observed staff supporting people per their care plans and risk assessments. For example, by ensuring a staff member was present to support a person in mobilising and supporting people with their health monitoring, such as blood pressure checks.

Systems to evaluate people’s care plans and risk assessments were not always effective. The provider's evaluations of care plans and risk assessments did not identify that a person who held on to furniture as they moved around did not have these secured to the wall, increasing fall-related risks to them. Where a person was known to communicate their emotional distress by using water, outlets in the home exceeded national guidance about how hot water should be in care settings to prevent scalds. This was despite the registered manager having completed a risk assessment and stating hot water temperatures had been locked to a safe limit.

People and their relatives did not raise any concerns about the safety of the environment. One person told us, “It’s lovely my room.” A relative said, “The house is a nice environment, the garden is maintained, and [person’s] room is personalised.”

The registered manager told us they held their hands up in relation to our concerns about environmental safety and responded with an action plan. However, the registered manager also talked us through the changes they had made to the environment in line with external health professionals’ advice to promote people’s safety. For example, they told us automatic lights had been fitted to support a person living with visual impairment.

The environment was not always safe and managed in line with published guidance. Hot water outlets were too hot, and not all radiators were covered, which increased the risk of burns to people. Window restrictors had not been fitted to all windows, and where they were, they did not always ensure window openings were restricted enough; this increased the risk of falls from heights to people. We identified issues with several fire doors in relation to excessive gaps and intumescent strips, increasing fire-related risks. A handrail was not adequately secured to the wall, increasing falls risks to the person who needed this. The car had a tyre with tread below or close to the legal limit.

Per our observations, the provider did not always effectively manage environmental risks and did not identify these concerns independently. However, as a result of our findings, the provider took action: they fitted window restrictors, had plumbers address hot water issues, replaced the car's tyre, measured radiators for fitting covers, secured the handrail and surveyed fire doors.

People and relatives gave us positive feedback about staffing. A relative said, "I find the staff very pleasant and engaged with residents."

Staff told us they received regular supervision and felt well-supported by managers. A staff member said regarding supervision, “It’s useful; I have a chance to raise any concerns or issues and help to identify any training I need. A manager told us if there were any shortfalls in staff practice, they would address this during supervisions. Overall, staff felt there were enough staff.

We observed people had been left in the care of staff who did not have training to administer their prescribed epilepsy emergency rescue medicine. This meant increased health risks to people should they have experienced an epilepsy-related medical emergency.

Due to our observations in this part of the report and feedback from staff in the medicines optimisation part of the report, we could not be assured staff had received all of the training they needed. The recruitment records we reviewed did not detail staff responses to interview questions. This meant we could not be assured the provider operated robust processes to gather all relevant information to confirm that the potential candidate was of good character. Documents such as staff supervision, employment contracts, staff competencies and parts of people's care plans were signed using the same word-processed font in the staff member's name. This meant we could not be fully assured of the credibility of these documents. This is covered more in the well-led part of the report. However, Disclosure and Barring Service (DBS) checks were carried out on staff. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff schedules showed enough staff were deployed.

People were involved in keeping the home clean, including tidying and cleaning communal areas and their bedrooms. People and their relatives did not raise concerns about infection prevention and control.

Staff feedback indicated some improvement was needed to consistently promote and manage infection prevention and control. During our second visit, a staff member checked an inspector’s temperature and asked them to complete a COVID-19 declaration form. Furthermore, they informed us this was their local policy. However, they could not show us this had been done for other recent visitors, and this had not occurred during our other visits. However, staff confirmed they always had access to enough PPE.

Some areas of the home needed refurbishment to promote infection prevention and control. For example, gaps between the flooring and kitchen cupboards could increase the risk of germs harbouring. We identified concerns in relation to how staff recorded fridge and freezer temperatures, and some opened foods had not been labelled or stored in the fridge where they needed to be. This increased the risk of food not being safe for consumption. However, other communal areas and people’s bedrooms were clean.

As per our observations, improvement was needed in this area. However, the registered manager took action to resolve our concerns about fridge and freezer temperatures.

A relative said a person was well "looked after" in relation to the support they received with their medicines. Records showed that wherever people could, they had been involved in assessing the level of support they needed in relation to medicine management.

A member of staff told us they had received training in relation to emergency rescue medicine for people living with epilepsy, but the provider’s training records showed they had not. Furthermore, when we asked the staff member how and when they would give a person this medicine, their response presented significant safety risks to the people who needed this rescue medicine. Another staff member told us they did not have this training when the provider’s records stated they did.

Improvements were needed to ensure people's medicines were always safely managed. Protocols for 2 peoples as required (PRN) emergency epilepsy rescue medication were not held on the medicines file, increasing the risk of staff not having important information quickly to hand in an emergency. Another person's PRN protocol for a medicine for their heart condition did not include a specific important safety instruction to guide staff. A PRN protocol had not been reviewed when it was due to be, and staff told us information on this protocol was no longer current. Where a person needed to have their dose of medicine spaced evenly, this was not always the case, and there was no rationale as to why staff had not maintained even spacing of doses. When we identified a missing dose of a medicine, a staff member told us they recalled the medicine had been destroyed in the car having been sat on. However, no incident or accident reports were completed concerning this, and this medicine had the potential to be misused. Topical medicines were not always dated upon opening, increasing the risk of people receiving medicines that were no longer safe for use. In response to our findings about medicines related safety concerns the provider sent us an action plan detailing improvements made in response to some of our concerns.