Ravenstone Care and Rehabilitation Home

“The home was not registered as a specialist service for people with autism or a learning disability. There were 2 people living at the home who had a learning disability, however, they did not receive personal care and therefore did not fall within the scope of the regulated activity.”

“While we were not assessing the care provided to these individuals, we would still expect the registered manager to have an awareness of relevant national guidance. The registered manager was not aware of the guidance ‘Right Support, Right Care, Right Culture’, which sets out expected standards to ensure that people with a learning disability and autistic people are treated with dignity and respect, experience equality, and are supported to have choice, independence, and meaningful access to their local communities. As the registered manager was not aware of this guidance, the service had not been mapped against these principles.”

“We found 4 breaches of the legal regulations relating to safe care and treatment, safeguarding people from abuse and improper treatment, duty of candour and governance.”

“Systems to safeguard people and manage risks were not effective. Required safeguarding notifications had not been submitted to the CQC, which limited external oversight of risks to people.”

“There were shortfalls with the environment. Fire safety checks, drills and training had not been completed as planned and fire doors were not always suitable. In addition, routine health and safety checks, such as water temperature monitoring had not been carried out as planned.”

“Equipment and environmental adaptations intended to promote independence were not always identified, in place, or reviewed. This included gaps in the provision of appropriate support equipment, such as aids to support safe mobility and reduce the risk of falls.”

“Accidents and incidents were not analysed to identify trends, themes, or repeated risks, and opportunities to reduce the risk of recurrence were missed. In addition, records did not demonstrate that duty of candour requirements had been met, as there was limited documented evidence of appropriate apologies, follow‑up actions, investigations, or lessons learned following safety incidents.”

“Care plans and risk assessments did not detail the actions being taken to manage identified risks. This included a lack of recorded actions to reduce people’s risk of accessing stairs, supporting people safely in relation to their behaviours and responding to weight loss. As a result, staff did not always have clear guidance to follow, which increased the risk of inconsistent care and meant people were potentially exposed to avoidable harm. In addition, an effective system was not fully in place to ensure medicines were managed safely and in line with best practice.”

“Although a staffing tool was in place, this was based on dependency levels and allocated…”