Roman 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

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. During our assessment of this key question, the provider failed to ensure medicines were managed safely. This resulted in a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider failed to ensure appropriate staffing levels to make sure people received consistently safe, good quality care that met their needs. This resulted in a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified some safety concerns in relation to the environment. You can find more details of our concerns in the evidence category findings below. People were effectively protected from the risk of abuse.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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 protected from the risk of abuse and told us they felt safe living at Roman House. One person said, "I'm safe, they [staff] are very good on the whole."

Staff understood how to protect people from the risk of abuse. They had received training on how to recognise and report abuse and they knew how to apply it.

People appeared relaxed around staff, and we observed staff to treat people kindly and respectfully. Posters about safeguarding were on display so those in the service had accessible information about abuse and how to report it.

The provider had safeguarding policies and processes in place to protect people from the risk of abuse. These had been recently discussed at a staff meeting to aid staffs understanding. A safeguarding log was in place, and this showed safeguarding concerns were shared with external agencies. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). DoLS applications had been made as required. However, we did find that 1 application had not been received by the local authority and this had not been chased up by the provider despite it being sent 2 years ago. The provider reapplied at the time of the inspection and told us of their plans to make improvements to their processes. Staff understood the need to gain consent from people for care and to encourage people to make decisions for themselves. Where there were doubts about people’s capacity, mental capacity assessments had been undertaken appropriately.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff and leaders told us there were issues with the environment. The provider told us they often faced delays and challenges with the landlord to ensure the home and equipment were well maintained. For example, 1 staff member said, “We report issues to the manager, but the landlord takes ages to do anything.” Staff understood their responsibilities for checking equipment and making sure they knew how to use it. A new risk assessment had recently been implemented to ensure bed rails were used safely and staff were aware of this.

Some areas of the home needed maintenance work to meet safety and hygiene standards. For example, in 1 communal bathroom the flooring was coming away from the wall. In a person’s bathroom, pipes had not been sealed as recommended by an external health and safety worker and a shower drain was missing. We additionally noted a burnt plug socket and areas of the home that were not always clean. Most of these issues were promptly rectified but we were concerned we were required to point them out for the work to be done.

Processes to monitor the safety of the environment were not always in place or effective. This was in part, because the provider was not always clear whether areas of ensuring a safe environment were theirs or the landlords responsibility. For example, we identified shortfalls about fire safety and Legionella management. These were resolved after our site visit. Records demonstrated equipment checks had either not been carried out effectively or action taken as a result. For example, faults had been identified with a wheelchair and a hoist, but timely action had not been taken to fix these. The provider had plans in place to improve this.

Equipment to support people safely was not always available. For example, there was no suitable lifting equipment for 1 person when they fell.

Staff raised concerns about staffing levels. They told us staffing levels were frequently lower than what the nominated individual told us they should be. For example, a staff member said, “9 times out of 10 we are short staffed.” Staff explained how this impacted on the safety and wellbeing of people. Examples included people not getting their one-to-one support and people being left unattended when assessed as requiring staff supervision. A staff member said, “This can make them [people] more anxious, affect health needs and they’re not getting out in the community.” Another staff member said, “This [staffing levels] creates a risk to people. It affects our ability to do other things such as checks.” 1 member of staff told us they were hopeful staffing levels would get better as the new manager had started picking up shifts. The manager confirmed this and when we spoke to the nominated individual, they told us they would review staffing arrangements.

Processes to ensure people were supported by enough qualified, skilled and experienced staff were not effective. This increased the risk of harm to people. The provider did not use a tool to determine the level of support people needed to assure themselves staffing levels were safe. Instead, staff were deployed based only on funding from the local authority. However, rotas did not show this was met and demonstrated a shortfall of staff. Audits in June, October and December 2023 all identified concerns with staffing. Despite this, appropriate action had not been taken and staffing levels still fell short. Before December 2023, staff had not received sufficient training to carry out their roles safely. In addition, staff had not received supervision as per the providers policy. This meant staff had not received the training or support to ensure they were appropriately skilled to fulfil the requirements of their role. Following our site visit, improvements were made, and staff received sufficient training and supervision.

People were positive about the staff who supported them. Comments included, “They're [staff] alright as well, [manager] is nice.”, "They're [staff] quick to help I think." and "They [staff] come if I need them, if I need phone calls, they do it for me."

During our site visit we noted staff were busy undertaking the tasks they were required to do. There was little interaction between staff and people, although when staff did spend time with people, they appeared to know them and their needs well.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff provided inconsistent responses about risks associated with some people’s medicines. For example, 1 person was prescribed medicines that thin the blood. There are risks associated with these such as increased bleeding. Not all staff understood these risks. Staff told us if they were unsure of the instruction on the medicine administration record (MAR), they would seek advice from a GP or the manager before administering them. However, the interim manager told us for at least 2 people’s prescriptions, they were still unsure on the dose. They required prompting from an inspector to prioritise this.

The provider did not always have processes in place to ensure medicines were managed safely. When prescriptions were unclear, the service did not clarify these with the prescriber in a timely way and staff continued to administer them with unclear instructions. Staff did not always countersign handwritten instructions on MARs to ensure they were correct. We also identified some signature gaps on MARs with no evidence these had been followed up by the provider. This meant people were at risk of not receiving their medicines as prescribed. Medicine care plans and risk assessments did not always contain the correct information. This meant staff may not have enough, up to date or correct information about people’s medicines and the risks associated with them. When people were prescribed topical creams, MARs did not include where on the body or when the creams should be applied. This increased the risk of creams being applied incorrectly. The recording of ‘as required’ (PRN) medicines was unclear. Therefore, it was difficult to establish when or why these medicines had been given, whether they had been effective or whether any follow up was required. During our site visit we witnessed a medicine error. We were not assured from the response by staff members of their understanding around this. This increased the risk of harm to people and medicine errors going unreported which could lead to missed opportunities for learning.

1 person told us “They [staff] help us with all of that [medicines] too.” Another person liked to deal with their own medicines which was respected by staff.