Archived: Rainscombe House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People did not receive effective care: although people were supported to access healthcare when required, staff failed to follow professional clinical guidance which had a detrimental impact on people's health and well being. People were not at the centre of their care: staff and leaders did not embrace effective communication with partners, or implement robust continuous monitoring tools to ensure people's needs were met.

This service scored 42 (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 Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

While the relatives we spoke to expressed that they were generally happy with their loved one's care, our assessment found care did not meet the expected standard. Although people had access to healthcare professionals, people's care and support was not coordinated: staff consistently failed to follow professional guidance which meant avoidable risks were not mitigated, and people were at risk of harm

Staff and leaders did not work effectively to ensure people received appropriate support. Although staff were able to demonstrate where they contacted a health care professional in relation to marks on one person, we found multiple instances of where people were receiving care from a range of staff and services, but staff had failed to follow clear guidance and had not supported people to be as well as possible. The risks to people’s life and health were not understood or prioritised by staff or leaders.

Partners told us communication was poor and needed improving to ensure people’s health needs were met. One partner told us: “Feedback is that the service are not forthcoming. They have really struggled to get information.”

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

People did not have coordinated care and support: staff did not always consider people’s well-being when activities were organised or record information in a consistent way to monitor people’s health. People were not seen by staff as individuals, and this had a consistent detrimental impact on people’s lives.

Although staff told us they referred people to healthcare professionals, their failure to work within recognised evidence based clinical guidance put people at risk of harm. People’s expectations about their care and treatment were not considered or met by staff and leaders. There was a consistent failure to ensure people’s clinical needs were met, and an overall failure by staff and leaders to continually monitor and improve people’s care.

Systems in place did not support people’s well-being and outcomes. Staff took one person to a party on the first day of assessment. We read in this person’s care plan, ‘I do not like parties and will become very agitated’. We read in this person’s daily notes the following day this person was distressed after the party and lay down on the ground refusing to move. This same person had also been prescribed glasses and although their care plan recorded they should be reminded throughout the day to wear them and if they refused this was to be recorded in their daily notes we did not see or read this was happening. On both visits, this person was not seen wearing their glasses. This person also had a digestive issue which meant staff needed to record their bowel movements and give them medicine if they had not opened them for 3 days. Although there was a bowel chart on the electronic care planning system, staff were not filling this in consistently. For example, we saw for a consecutive period of 7 days in July there were no entries and in June, staff had only completed the monitoring form on one day. We reviewed the daily notes for this person over the period of these 2 months and could see that staff were using these to record the person’s bowel movements. We did not note any time periods of 3 days or more when they had not had one. Despite this, without the robust use of the monitoring tool, it would not be easy for staff to identify when this person last had a bowel movement and as such they could go without their necessary medicine. We read staff had been reminded on completing these records in supervision, but continued monitor of compliance had not been carried out to improve staff practice and improve outcomes for people.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.