Royal Court Care Home

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

During our assessment of this key question, we found concerns around the management of people's medicines, the management of people's risk and infection control which resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. People were not safeguarded from abuse and avoidable harm. The provider had not ensured there was an effective system in place to ensure people’s risks were managed effectively and people’s safety and independence was promoted. The systems in place to learn from accidents and incidents required improvement. Robust recruitment procedures were in place. There were sufficient staff at the service. Staff had received training relevant to their role.

This service scored 41 (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 did not always learn lessons when things had gone wrong. The systems in place to learn from accidents and incidents required improvement.

People felt confident they would be treated with understanding if they raised concerns.

Some staff did not feel supported to raise concerns. They felt the registered manager would not maintain confidentiality and this would result in them being treated negatively. This showed there was a risks that concerns would not be reported appropriately.

Positive relationships had been made with other healthcare agencies involved with people's care.

We received some mixed views about the quality of care provided and the involvement of other healthcare agencies. Some people shared details of all the different healthcare professionals involved in their care. Some relatives felt staff needed to follow up referrals to healthcare professional more often.

Processes were in place to enable a smooth transition between services and to reduce the impact on people. The quality of some people's care records and/or medication records had insufficient detail to enable effective information sharing.

We received mixed feedback from partners. The local authority shared concerns about the quality of care and safety of people using the service. During our site visit two healthcare professionals gave positive feedback about the service.

People told us they felt safe. The relatives spoken with told us their family members were safe but there were some issues around communication, hygiene, fluids, and staff training. Some relatives felt staff did not always approach people appropriately when they showed behaviour that challenged.

Staff were able to recognise possible signs of abuse and knew how to report such concerns. However, some staff told us they did not feel comfortable raising concerns with the registered manager due to a lack of confidentiality.

We could not be confident people were safeguarded from abuse and avoidable harm. The feedback from staff showed there was risk concerns may not be reported. We observed unsafe practice with regards the moving and handling of people in hoists. People’s risks were not always being managed safely. There was an increased risk that people could be harmed.

The registered manager understood their responsibility to refer any safeguarding matters to the appropriate agencies. However, the feedback from some staff showed there was a risk concerns would not be reported appropriately to the registered manager. The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service was aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

The provider had not ensured there was an effective system in place to ensure people’s risks were managed effectively and people’s safety and independence was promoted. Individual risk assessments were completed for people. However, one person did not have care plan in place to manage their risks related to Oedema. This placed the person at risk of not being supported safely. Another person did not have any guidance in place for staff to follow if they had a choking incident. When people communicated their needs, emotions or distress, staff could not manage this in a positive way that protected their rights and dignity and maximised learning for the future about the causes of their distress. The provider had failed to ensure one person had a positive behaviour support plan in place to guide staff on how to support a person during incidents. Records did not evidence that staff learned lessons from these incidents. This placed the person at risk of receiving unsafe support.

Staff were not always aware of people’s moving and handling risks. Hoist slings were used generically placing people at risk of unsafe moving and handling. Care records did not always provide guidance to staff about how to safely care for people. For example, if a person had behaviours which may challenge.

We received mixed reviews about the management of people’s individual risk. Some relatives felt their family member’s risks were managed well. However, some relatives felt their family member’s risks could be better managed.

People were at risk of unsafe moving and handling. The provider had not ensured each person had a suitable hoist sling and there was clear guidance for staff to follow on how the sling should be used. Risks related to bed rails were not managed effectively. For example, one person’s bed rail bumpers were not suitable to prevent the risk of entrapment. We observed a choking incident. The person had not been appropriately supported to reduce their risk of choking. The consistency of the person’s meal had thickened whilst stood and a staff member was not sat with the person. The person’s care plan did not have any information on how staff should respond during a choking episode. Staff did not record the choking incident in the person’s daily notes.

The deputy manager told us the provider was in the process of moving all care plans from paper based to an electronic system.

People had a range of equipment available to use. At the time of the assessment people who could not mobilise were unable to choose to have a bath as there were no assisted bath facilities available. The provider was in the process of refurbishing the bath facilities.

There were arrangements to monitor the safety and upkeep of the premises. Environmental safety checks were in place, ensuring the environment and equipment was safe for people to use. This included fire safety, legionnaires and lifting equipment precautions. However, our observations showed the bed rail and hoists checks required improvement to ensure people were not at risk of entrapment or unsafe moving and handling.

We saw evidence that environmental and equipment checks had been completed. Equipment was available in different areas of the service for staff to access easily. However, there was no assisted bath facilities at the service. This meant people who could not mobilise were unable to choose to have a bath if they wished to do so. We also observed concerns on how staff used the hoisting equipment.

Robust recruitment procedures were in place so people were cared for by staff who had been assessed as safe to work with people. The registered manager used a dependency tool to assess how many staff were needed. This was regularly reviewed to ensure there were enough staff to meet people’s needs. Records showed that staff received training and supervision. However, some staff had not received regular supervisions in line with the provider’s own policy. Staff had received behaviour that challenge training to support people during periods of distress. Relative's and staff feedback showed staff would benefit from further training to develop their knowledge and understanding.

Staff told us there were enough staff deployed at the service and the number of staff increased with the number of people using the service. Staff told us they received training relevant to the role. Some staff told us they did not feel supported in their role.

Safe staffing levels were in place at the service.

We received mixed views from people about the staffing levels and staff training. People’s comments included, “You wait a couple of minutes for them [staff] to respond to the call bell. There are enough staff and it's a regular staff team” and “They [staff] are very busy, and they could do with some more staff, but you don't necessarily wait long, it's just on the morning when they're getting people ready.” Relative’s comments included, “The staff seem static, not much turnover which is good but there are not enough staff at weekends” and “There are now enough staff, care and staffing levels have improved. The staff are not trained well enough, there are a lot of new ones, a lot of young ones so there is a lack of experience.”

People were not always protected from the risk of infection. Areas within the home were visibly dirty. Chairs in people's rooms were visibly stained; several pedal bins were broken and PPE was not stored correctly. The provider informed us they had ordered pedal bins and six commode chairs prior to our assessment and were waiting for them to be delivered.

The visual checks undertaken by senior staff to ensure infection control was being managed well by staff required improvement. For example, the walkabout completed by the deputy manager at the beginning of February 2024 had not found any issues relating to infection control. Staff had not ensured people were protected from the risk of infection because premises and equipment were not kept clean and hygienic.

The systems used by the provider to monitor infection, prevention and control practice were not effective in practice and did not ensure people were always protected from the risk of infection.

People were able to receive visitors in line with best practise guidance. We received mixed views about infection control at the service. Some people and relatives spoken with did not have any concerns and told us the home was clean and staff wore personal protective equipment (PPE). One person told us staff did not always wear PPE. Some relatives shared concerns about the cleanliness of equipment provided to their family member and poor hygiene.

Staff involved in the handling of medicines had received training about medicines. Staff were assessed as competent to support people with their medicines. However, the systems in place to check staff handled medicines safely required improvement.

People and relatives did not share any concerns about the management of medicines. However, our findings during our site visit showed we could not be confident that people were being supported appropriately with medicines.

The systems used by the provider to ensure medications were managed safely required improvement to ensure people were protected from the risks associated with medicines. Medication was not always recorded appropriately. Medicated creams and medicated patches prescribed on an 'as required' basis, (PRN) did not have protocols in place for staff to determine when to administer them. Therefore, it was not clear if these medicines were being given as prescribed. Several items including lactulose, liquid paracetamol and eye drops did not contain open date labels. So, it could not be determined if they were safe to administer. One person’s eye drops were not being stored appropriately and another person did not have a medication administration record for a prescribed medication.