Archived: Rainscombe House

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• 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

We found three breaches of the legal regulations in this key question. These related to safe care and treatment, safeguarding people from abuse and staffing. People were being given foods inappropriate for them and staff were not always observing people at risk of choking when they were eating. Staff were not fully competent in medicines management and were seen following poor practices. The garden was unsafe for people and staff were seen carrying out poor infection control practices. People were at risk of financial abuse and there was institutionalised neglect towards people and a closed culture within the service. There were insufficient staff on duty to meet people’s 1:1 needs when they went out together. In addition, night staff were given a break during their shift yet they were the only night staff member in the home. Some staff’s training had expired which meant they were putting people at risk of harm.

This service scored 25 (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’s family member’s were not always told of incidents. A relative said, “I received contact from the police and had to phone the care home and ask what was going on.” People were not supported to understand risks. Leaders and staff put people at risk of ongoing harm through neglect and acts of omission. For example, when risks to people were known, such as choking risks, leaders and staff did not follow guidance from professionals.

Staff told us they had undertaken safeguarding training. Despite this, staff and leaders had failed to ensure people were safe from abuse. We identified institutional neglect, poor financial records regarding individual’s money, a closed culture, and a disregard to people’s health conditions. Staff and leaders had no recognition of their responsibilities, or their failures in ensuring people lived their lives safely, free from avoidable harm and neglect.

Systems and processes to ensure people were safeguarded against abuse, harm and neglect were inadequate. Staff and leaders did not have a strong understanding of safeguarding. There was no evidence or records to demonstrate a robust understanding and adherence to recognising all types of abuse, and taking appropriate proactive action to prevent abuse from occurring. Leaders had not fostered a culture of collaborative working with partners: this led to increased isolation of people, and the continued growth of a closed culture. People’s safety and their human rights were not recognised or acknowledged by leaders or staff. If people had concerns about their safety, there were no processes in place to ensure they would be supported or listened to.

People were at risk of harm by staff. People were not supported by competent staff or leaders, and risks were not managed safely. For example, although risks to people’s health were known, professional guidance was not always followed.

Staff felt the risk of harm to people had lessened due to a better understanding of their duty of care, however our observations and review of records did not support this. The registered manager told us, “Staff report everything now. They didn’t even know how to fill out an incident form before.” A staff member told us, “[Person’s name] does not like people to sit close to him, so we encourage them to sit somewhere else (to reduce the risk). We try to encourage positive behaviour. We can tell the manager if there is an incident.” Yet staff continued to provide people with inappropriate foods and they lived in an environment that was not always safe.

Staff continued to leave people at risk of harm as they were not following guidance in care plans, particularly in relation to people’s eating and drinking. A person who required their food cut into small pieces and given using a 2-plate system (using one plate to put small amounts on it) was seen eating a whole apple, without staff supervision. They ate everything, including the core and pips. Their care plan stated they could take fruit from the bowl and staff needed to be alert as all foods had to be cut small and given to them one piece at a time. A second person required their food cut into pieces and for it to be of a moist consistency, not dry, and yet we reviewed this person’s daily notes and read this person was being given crisps and biscuits by staff. We found 2 staff who worked at the service regularly had not undertaken dysphagia training. This training was important as 2 people were at risk of choking and as such staff needed to have an understanding of techniques on how to reduce this risk. Each person required 1:1 support when out in the community. Despite this people often went out together and as such this meant that people may be at risk because there would be insufficient staff as only 2 staff were on duty at the service.

Although guidance was included in people’s care plans, such as eating guidance from the Speech and Language Therapy team, staff were not always following this. Audits and management observations had not identified that people may be put at risk by poor staff practices. We read from people’s daily notes that staff were cutting or trimming people’s fingernails. The cutting or trimming of people’s nails should only be done by staff who have had their competency assessed to do this. We did not see any competency assessments for staff and there was no risk assessment around this for each person. In addition, each person should have their own clippers and emery boards. This left people at risk of being cut and receiving an infection.

People’s environment was hazardous and harmful: people’s garden had items in it that could cause them harm. This had not been recognised by leaders or staff.

Staff were not aware of the state of the garden and how it posed a risk for people. The registered manager told us people used the garden more and staff told us they had replanted the garden. One staff member said, “Have you seen the flowers outside. I planted them.” Yet, the garden was unsuitable for people.

The garden was not suitable for people’s use. There was a disused radiator against the wall with a large shard of glass leaning up against it. A step ladder was up against the fence which people could potentially climb. There were bin liners and rubbish as well as metal strips on the ground. There was also a bag of garden compost and a large metal bin with a rusty foot pedal. The grassy area had deep ruts in the grass which someone could trip down and the rear gate was unlocked and left open meaning people could access the old farm barns.

Although there were environmental audits carried out by a senior manager on a monthly basis, these had not identified the poor condition and unsafe features of the garden. Both the registered manager and the staff member who had replanted the flower bed were unaware of the potentially dangerous items in the garden. Following out visit, the registered manager shared garden risk assessments for all 3 people living at the service, these recorded people should always be accompanied into the garden. However, we noted these risk assessments were only written on 6 August; the second day of our assessment visits. Other aspects of the environment were safe as checks were carried out in relation to fire extinguishers and electrical testing. These areas were compliant and had been recently checked.

A relative told us they usually had weekly contact with staff and that her family member had various keyworkers over the years but, “Some don’t stay long.” They also said, “Mostly when I have been there (to the home) I always see at least one person (staff member) who seems confident. They sometimes have agency staff who aren’t quite as much in the know about how things worked.” We found however, people did not receive safe care in line with their needs due to inadequate staffing levels and competency.

Staff and leaders demonstrated a lack of insight into people's safety and how this related to having consistent sufficient numbers of trained and competent staff deployed to ensure people's needs were met. Staff told us they felt there were enough of them on duty. A staff member told us, “Yes. I think there is enough staff. Today I am on the rota for the bungalow, but [staff name] is taking clients out, so I have been here (the house) all day.” Although we found this not to be the case as when we arrived this staff member was not on site. Professionals told us they had concerns about staff, “Floating” between homes. They told us following a visit to Rainscombe Bungalow, “When we left we sat in the car to debrief and saw 2 staff leave Rainscombe Bungalow to go into Rainscombe House.”

During our first day of assessment we arrived to find only one staff member on duty. We were told the second staff member had gone to the provider’s neighbouring service, Rainscombe Bungalow as a driver was needed. A staff member from the bungalow arrived at Rainscombe House 10 minutes later, however we are unsure how long this one staff member had been on their own at the service. During our second visit to the service we met with the staff member who had been on duty during the night. We saw them providing care to all 3 people, trying to ensure that one person received their medicines when required, making breakfast for everyone and trying to support someone safely when they wished to go to the toilet. The staff member was unable to observe everyone at all times and if there had been an emergency it would have left people and this staff member vulnerable. It also meant one person who was at risk of choking was able to eat a whole apple without supervision and another person who required prompting and encouragement to eat was left eating their breakfast alone. We also read in people’s care plan they all required 1:1 support when out in the community. As there only 2 staff on duty and people often went out together this meant that people may not have sufficient staff to meet these requirements.

Staffing was inadequate: there were insufficient skilled, experienced and trained staff deployed: this impacted people’s safety. Rotas showed some staff had been rostered to work both at Rainscombe House and another service at the same time. On 4 occasions in June staff were expected to be in both services. This placed people at risk due to insufficient staff to provide their care. One staff member rostered to work nights had let their medicines training expire on 4.2.24. A second staff member said this did not matter as they did not administer medicines at night. However, one person was prescribed a rescue epilepsy medicine which needed to be administered after 5 minutes, this could leave the person at risk. Only one member of staff was on duty at night but we found they were given a 20-minute break with no other staff to provide care to people during this time. At this assessment records indicated training compliance had improved. The registered manager told us, “Training is now 93%. It was 12%. I’m not sure how it was allowed to get so bad.” Despite this, we identified 2 staff had not received dysphagia training and other staff’s training had expired. For example, the first aid training for one staff member and a staff member who worked the night shift had not refreshed their basic life support training. In addition, there were no processes in place to ensure staff competency following training. Our observations and records reviewed showed that although training compliance had improved, it was not effective in ensuring staff were skilled or competent, and people continued to receive unsafe care from leaders and staff. Staff were recruited safely. We read they provided details of their previous roles, their fitness to carry out the role, their right to the work in the UK and references. Staff underwent a Disclosure and Barring Services (BBS) check prior to commencing in their role.

People lived in a service which was in a reasonable state of cleanliness and staff used appropriate personal protective equipment, although staff were not always following good practice.

Infection control checks and audits were carried out. The registered manager told us, “The seniors do an infection control audit, followed by my monthly oversight audit. It then goes to the provider to do theirs as well as physical spot checks.” Yet, these audits had not identified poor practice.

Although the service appeared clean, there were areas which could harbour dirt. The grout in the floor tiles in one person’s bathroom had broken up leaving large holes between the tiles. This would make it challenging to clean effectively. And the leather on one chair in the lounge was frayed which may prevent effective cleaning due to the fabric becoming porous. We saw floor mops stored in an old rusty metal household bin outside. Although these were stored mop head up, cleaning equipment should be stored clean and dry after use in a designated area. By leaving them outside this meant they would be exposed to the weather and as such could harbour germs if they were unable to dry properly or they were exposed to the sun when damp. However, we observed staff regularly washing their hands and using appropriate infection control equipment when moving between tasks. For example, between preparing people's food or supporting a person to the toilet.

Processes to ensure safe infection prevention and control were not robust. Staff and leaders had not prioritised infection prevention, and although staff had received training regarding this, they had not applied the training. In addition, although health and safety audits were carried out these were insufficient and had not identified areas where safe infection prevention and control were compromised. For example, mops were stored outside in a rusty bin, care staff had cleaning schedules, but it was not clear that they were following safe infection control practices, for example: care staff were also responsible for assisting people with personal care, laundry and food preparation along with cleaning. Separating these tasks to ensure there was no risk to people’s health in terms of cross infection was not checked by staff or leaders.

Although records showed people received the medicines they required, people were at risk of not receiving essential medicine for prolonged seizures, as not all staff had been trained, and there were inadequate staffing protocols at night to ensure people’s safety at all times.

Staff received medicines training and told us they had their medicines competency checked. One staff member told us, “I’ve had a competency check and I was observed and told what to improve before being signed off.” Yet, we found staff were not always competent in good practices around medicines management.

Although staff recorded the medicine cabinet temperatures and temperatures were checked as part of the review of daily handovers, as well as through management audits, no one had taken any action in response to the high temperature of the cabinet on one occasion. This meant that one person’s medicine in particular could be ineffective as it had not been stored in line with manufacturers guidance. We asked both the IT manager and the senior staff member on duty to contact the pharmacy to request a replacement medicine. The providers medicines policy stated staff must demonstrate an understanding of how to read and reset the thermometer, and why this is necessary. We spoke with 2 staff about this and neither were able to show us how to reset the thermometer. Staff were trained to give medicines and had their competencies assessed. However, we noted one staff member’s medicine training had expired on 4 February 2024 and the records showed another staff member completed their training in the future (7 August 2024). This meant the records may not always give an accurate position on staff competency and their knowledge of good practice.