Archived: Rainscombe Bungalow

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

The principles of RSRCRC were not met as the model of care provided did not allow people to live empowered lives with maximum choice. The risks associated with people’s care were not always being managed in a safe way and there was not always sufficiently qualified and trained staff to support people in a safe way. People were not always receiving their medicine as prescribed. People were not always being protected from the risk of abuse. Incidents were not always being reported or investigated to reduce risk of reoccurrence.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the relatives we spoke to did not raise concerns about incidents, our assessment found care did not meet the expected standards: people were not always protected from the risks of being harmed, or the risk of incidents re-occurring. A relative told us they were always informed when their loved one had an incident. However, we were aware of high levels of anxiety of their family member where the relative had not been informed of at the time.

Staff told us they would complete forms when incidents occurred and inform the registered manager however this was not always happening in practice. The registered manager told us staff would make them aware of any incidents and that the registered manager would raise an incident form. However, we found this was not always taking place meaning actions were not always being taken to investigate the incident and opportunities for learning were being missed.

There was a lack of analysis of people’s heightened states of anxiety to look for trends and themes to reduce further risks to people. For example, we saw from 1 person’s care notes there had been 2 instances of the person exiting the home and running into the road. Neither of these incidents had been reported to the registered manager. We saw from another person’s care notes, they were at high levels of anxiety throughout the day. This was not recorded as an incident or raised on the person’s ‘Behaviour’ record. The Providers tracker lacked detail on what investigations took place to determine what may be the cause of some incidents. For example, 1 person was found to have a bruise. Although they were taken to the GP there was no consideration the bruise may have occurred due to an incident the person was involved in days before.

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.

One person fed back concerns about a member of staff. We reported this to the registered manager. There was mixed feedback from relatives and advocates on whether they felt people were safe at the service. Our assessment found care did not meet the expected standards.

Staff fed back they would report any safeguarding concerns. One member of staff said, “Call the head office and email to them and to us as well. I have never witnessed anything.” However, staff were not always recognising safeguarding concerns.

The provider failed to ensure people were protected from emotional and psychological abuse. We saw from 1 person’s care notes they were crying throughout a night shift. It was recorded every hour by staff that the person was upset yet no record of any support or comfort being provided. People were also at risk of financial abuse. We saw from handover records in May and June 2024 that the balance of people’s daily finances did not tally with what they had were recorded to have spent. This was not picked up by the Provider until we raised this with them.

The provider and registered manager reviewed care notes for incidents however this was not always effective in identifying where potential safeguarding concerns had occurred. Staff received training and there were policies in place however these were not effective.

There was a mixture of feedback from relatives and advocates about whether risks to people were being managed well. People were not always receiving safe care based on the risks associated with their health. We did not see evidence that people were involved in the management of risks.

Staff we spoke with did not have a good understanding of the risks associated with people’s care. For example, according to their care plan and the registered manager, 1 person was at risk of choking, yet staff told us they did not know this. Staff and the registered manager told us no one required to have the bowels and fluids monitored, aside from 1 person that had their fluids carefully managed and closely monitored. However, according to their care plans there were people that required their bowels monitored and fluids which would be good practice for all people living there. This is based on guidance NHS England that people with a learning disability are more at risk of health constipation that the general population.

The risks around people’s care were not being managed in a safe way. For example, 1 person needed staff to sit with them when they ate as they were at risk of choking due to them eating quickly. This did not take place during the assessment, and we observed the person did not receive any support when eating. Another person was at risk of choking and required small amounts of drink to be given to them to reduce the risk. We observed a member of staff tipped a cup of drink into the person’s mouth causing them to cough. The member of staff continued this until the drink was completed.

There were inadequate processes in place to ensure risks were managed safely. One person was assessed at risk of constipation, yet their bowel chart was not being monitored. There were 3 days where the person was not recorded to have opened their bowels and days where the type of stool recorded indicated possible constipation. The person’s fluid chart was also showing frequently they were having very low levels of drinks per day. Staff told us and we saw from care documents, 3 people who were either blind or partially sighted, were taken for local walks down the farm roads with no public foot paths which was directly on the farm road where the home was situated. There was no risk assessment in place in relation to this which needed to consider the uneven roads, traffic and no pavement. People were routinely having their hand nails clipped however there was no risk assessment in place in relation to this. Where people had high levels of anxiety, staff were not always recording that they were following peoples ‘Positive Behaviour Support Plans’. This meant that staff may not provide the most appropriate support to the person when they were at a heightened state of anxiety. The registered manager told us they, and another member of staff updated risk assessments. However, we found risk assessments were not always updated when a change occurred.

We did not receive specific feedback in relation to the environment from people, relatives or advocates. However, we found there were elements to the environment that were not always safe for people.

The registered manager told us staff were required to undertaken environmental checks daily. However, staff we spoke with did not always understand their responsibilities around this. According to care plans, staff were required to check the temperature of the water each time a person had a shower. However, 1 member of staff told us they only check this once a week. There was a fire door at the service that the registered manager told could be accessed by breaking the small glass box at the top. However, staff told us they would need to find a key in the office to open the door. This meant there may be a delay in evacuating people in an emergency if they needed to use this door.

We found elements of risks to the environment were not always managed in a safe way. We found the cupboard with cleaning products was left unlocked and open in the bathroom and was accessible to people. This concern was also raised by the local authority when they visited in February 2024. There were people who were visually impaired and at risk of falls. We saw there was a lead trailing from the television in the lounge onto the floor which was a trip hazard. The front door and front gate, that needed to remain locked due to people being able to access the road, was left unlocked on both days we visited, and we were aware that 1 person had run into the road on 2 occasions.

There were audits in place to check the safety of equipment and the building. However, they were not effective in identifying the concerns we found. There were no checks to ensure the front door and gate outside were secure. There were no checks in place to ensure staff were recording water temperatures when people had their personal care. There were no checks in place to ensure staff understood how to evacuate safely in an emergency given we found staff were not aware of how to exit one of the fire escapes in the lounge.

There was mixed feedback from relatives and advocates on whether there were sufficient staff to support people. One told us, “One to one care is needed but I am not sure this is happening.” The feedback we received was that they were not confident staff were adequately trained. We found people were not benefitting from a staff team that were sufficiently trained to support them in a safe way.

Staff told us there were sufficient staff at the service. However, staff we spoke with lacked the understanding of people’s needs. When we spoke to staff about specific conditions that people had, they lacked an understanding of this. For example, we asked 1 member of staff if they could explain what a learning disability was and autism and they said, “This I do not know.” The registered manager told us they had worked hard to ensure staff were up to date with their training. However, we found this was not effective to ensure this was effective in practice.

There were insufficient staff deployed, and an absence of adequately trained staff. we observed there were inadequate staff in terms of deployment and skills: this impacted on people’s safety. For example, we observed staff not safely supporting a person that was at risk of choking.

There were inadequate processes in place to ensure safe and effective staffing. When agency staff were required to cover shifts, they were not always adequately trained to support people. One agency staff that routinely worked at the service had not received any training in learning disability or autism. This was the same staff who told us they did not know what these conditions were. Supervisions for staff were not effective to ensure good practice. Most supervisions were recorded as ‘Reflective Practice’ where specific shortfalls had been discussed. There was a lack of evidence of a meaningful supervision where staff had the opportunity to discuss objectives, training needs and how they were feeling. The provider had determined that 4 staff were required on duty each day. However, we saw from rotas that on 3 occasions there were the same staff rotered to work at the home and the service next door. This meant staff were moving between both homes during the shift. There was 1 person that required 2 staff to be with them when they went out and 2 people that required 1 member of staff. This was due to the risks of their high levels of anxiety and mobility issues. However, given there were only 4 staff on duty, this restricted how frequently people were able to go out to external activities despite being funded for this.

We did not receive any concerns from people, relatives or advocates around cleanliness. However, we found people were at risk as staff were not always following good infection prevention control practices.

The registered manager told us they were responsible for ordering more stock of Personal Protective Equipment. They also said staff on duty would know where to access the excess stock in the home. Despite this we found some shortfalls around infection control.

On both days of the assessment, we observed the hand sanitizer in the hallway was empty. We observed staff assist people with their personal care whilst we were there and not use or replace the hand sanitizer. On both days, a chair in 1 person’s room smelled strongly of urine. This was also a concern at the previous Inspection in November 2023. On day 2, we observed a member of staff picking the skin off a sausage without gloves and then puree this for a person. We did observe that all the other areas of the home were clean and well maintained.

We asked the registered manager to send us all audits undertaken in the service. However, none of the audits we were sent specifically covered IPC.

Relatives did not raise any concerns around the management of people’s medicines. There was a risk however people were not receiving medicines when needed. We were not assured people always had access to medicines to manage acute conditions in a timely way which could prolong the time the person was experiencing symptoms. We saw from their care notes, in May 2024 1 person had been prescribed eye drops for an infection. However, it was a further 5 days before the medicine was administered to the person. There was no record to suggest staff had problems getting the prescription.

Staff that administered medicine were not always aware of the reasons people required the medicine. 1 member of staff told us they did not know why a person required a medicine 30 minutes before their breakfast. We saw there were times this was not adhered to. Another member of staff recorded in a person’s notes they received an anti-psychotic medicine for their seizure; however, it was administered for their high level of anxiety.

Staff were not always following the administration guidance in people medicine administration record (MAR). According to their MAR, 1 person, needed to have medicine in a small amount of water. However, we observed the tablet was dissolved into a larger cup of water. When the person was given the medicine, a lot dropped out onto their chin and chest. This meant the effectiveness of the medicine was reduced due to the volume of water used and subsequently the person did not receive the full dose. The audits of medicines were not always effective in identifying or addressing shortfalls. For example, in May 2024 the audit for 1 person’s MAR stated that all staff who were administering medicines were on the signature list. However, there was a member of staff night giving medicines whose name did not appear on this list. The audit also stated that there were no actions from the audit. However, it was identified by the auditor there was a lack of patient information leaflets available for each medication. There was no record that this had been addressed. Audits had also not identified the concerns we observed. Other aspects of the medicine administration were safe. Each person had a MAR with details of any allergies and GP details. There were no gaps on the MAR we reviewed. Creams and liquids had an open date on them, and staff were recording the temperature of the medicine cabinet which were all at a safe level. Where handwritten prescriptions had been added to the MAR, 2 staff had signed to confirm the administration details were correct.