Ryhope Manor 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

An effective safeguarding system was not in place to ensure people were protected from the risk of abuse. This was a breach of Regulation 13 (Safeguarding people from abuse and improper treatment) The environment and equipment were not always clean, well maintained or serviced in line with legal requirements. In addition, risks relating to people’s care and support had not been fully assessed. Medicines were not managed safely. We identified shortfalls in many areas of medicines management. These issues constituted a breach of Regulation 12 (Safe care and treatment). There were not enough staff deployed to meet people’s social needs. Following our feedback; activities provision was increased from 3 to 5 days a week. There was a lack of evidence to demonstrate that staff were suitably trained and skilled. This was a breach of Regulation 18 (Staffing). An effective recruitment process was not fully in place. The provider’s policy was not detailed and did not fully reflect recruitment practices at the home. Records reviewed did not evidence that right to work checks were carried out in a timely manner. This was a breach of Regulation 19 (Fit and proper persons employed). Records did not demonstrate how the provider was meeting their responsibilities under the duty of candour. This was a breach of Regulation 20 (Duty of Candour).

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst people and staff did not raise any issues in relation to the learning culture at the home; there was no evidence that accidents and incidents, complaints and safeguarding allegations were reviewed and monitored to identify any trends or themes and lessons learned so action could be taken to minimise the risk of any reoccurrence. This posed a risk to people’s health, safety and wellbeing Records did not evidence how the provider was meeting their responsibilities under the duty of candour in relation to notifiable safety incidents.

There was a preadmission procedure in place to make sure people’s needs could be met at the home. Staff, health professionals and people raised no concerns in relation to this area.

Whilst staff did not raise any concerns about staff practices at the home and people and relatives told us people felt safe; we found that an effective safeguarding system to ensure people were protected from the risk of abuse was not in place. This placed people at risk of harm. The correct agencies had not always been notified of safeguarding allegations, including CQC. The provider’s safeguarding procedure did not provide clear guidance about when the police should be notified. We identified shortfalls with the management of records relating to people’s monies. We passed this information to the local authority safeguarding team. 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). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. DoLS applications had been submitted by the home to the local authority; the outcome of these applications had not been notified to CQC which was not in line with legal requirements. In addition, records did not always demonstrate how staff were following the requirements of the MCA.

Whilst people, relatives and staff did not raise any concerns in relation to the management of risk; we observed an effective system was not in place to assess, monitor and manage risks. This placed people at risk of harm. Risks relating people’s care and support had not been effectively assessed, monitored or managed in relation to their specific medical conditions, pressure area care, medicines management and nutrition. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.

Whilst people and relatives did not raise any concerns about the environment; we found an effective system was not in place to assess, monitor and manage the risks relating to the environment and equipment. This placed people at risk of harm. The environment and equipment were not always clean, well maintained or serviced in line with legal requirements. We also identified shortfalls with fire safety, the windows and water system. Several staff explained that improvements were required with the environment especially the water system since not all taps worked effectively and they were having to carry warm water to some people’s rooms. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.

There were not enough staff deployed to meet people’s social needs. We received feedback from several people, relatives, health and social care professionals and staff that more staff to support people’s social and emotional needs were required. This was confirmed by our own observations. Following our feedback; activities provision was increased from 3 to 5 days a week. Whilst people and staff raised no concerns about staff training; we found an effective system was not in place to evidence that staff were suitably trained and skilled. In addition, regular checks to make sure there had been no changes with the nurses’ registration with the Nursing and Midwifery Council (NMC) were not carried out. An effective recruitment process was not fully in place. The provider’s reruitment policy was not detailed and did not fully reflect recruitment practices at the home. Records reviewed did not evidence that right to work checks were carried out in a timely manner. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.

Whilst people, relatives and staff raised no concerns about infection control; we found an effective infection control system was not in place. Risks relating to Legionella had not been fully assessed and not all areas of the home or equipment were clean. These shortfalls posed a risk to people’s health and safety. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.

Whilst people, relatives and staff raised no concerns about medicines management; we identified shortfalls with the management of time specific medicines; topical medicines, medicines administered on a ‘when required’ basis and oxygen management. There were gaps on the medicines administration records which meant it was not always clear whether staff had administered the medicines as prescribed and medicines care plans were not always clear or up to date. These shortfalls posed a risk to people’s health and safety. Following our feedback, management staff took action to address some of the issues identified and formulated an action plan to address the outstanding areas.