Archived: Rainscombe Bungalow

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leadership of the service was inadequate. There was a closed culture which was not person centred. A closed culture means a poor culture that can lead to harm, which can include human rights breaches such as abuse. Processes to keep people safe were not in place. People experienced institutionalised neglect, their distressed behaviours and anxiety were ignored and not acted upon to ensure people were safe and felt safe. People had unnecessary restrictions placed on them and their human rights were not upheld. Quality monitoring systems were inadequate. There were widespread failures by the provider and the registered manager to assess and act on risk. The provider and the registered manager had not been open and honest in line with their legal responsibilities. They had not shared information with CQC or with stakeholders. People and staff were not encouraged to speak up, and when they did, they were either ignored or treated poorly by the provider.

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.

Leaders did not role model a shared vision, strategy or positive culture to staff. This had a major detrimental impact across all areas of people's lives. Despite the registered manager telling us activities had increased and people were leading more meaningful lives, we found this was not the case. Staff and leaders did not know people well, and did not demonstrate the required skills or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a closed culture that did not promote or uphold people’s rights

Leaders had failed to have processes in place to enable and promote a positive and compassionate listening culture. Leaders instead had perpetuated an ongoing closed culture where learning and improvement was not prioritised, people’s human rights were not upheld, and leaders and staff were unchallenged in their institutionalised practice. There was a complete failure to involve people and external partners in meaningful and structured collaboration which promoted people’s human rights and safety. For example there were no systems in place to seek feedback from people, their advocates and external partners. The provider, registered manager and staff did not demonstrate any understanding of a people led service, based on shared values: the disrespectful and discriminatory language staff used to describe people in records demonstrated this

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders and staff did not value people or seek their views or feedback. There was a closed culture where the voices of staff and people were not seen as essential, valuable or important. Although staff told us they were able to speak up confidentially, we found in practice this was not always happening. Staff were asked to complete surveys however, they were asked to provide their name and email addresses. We found ‘free text’ areas of the surveys completed by staff were often identical to each other. This was despite the registered manager telling us were able to speak freely to them.

There were inadequate processes in place to ensure people and staff felt empowered to speak up. We saw from staff meetings; staff were not asked to contribute to any concerns they may have. There were authoritative and negative notes left in the staff communicate book including, ‘Order by (the Provider)’ and ‘This is the last time I tell you night staff…’ which did not promote an open culture. People had no voice at the service, the one process in place to support people to speak up was key worker meetings: these did not take place. The provider and registered manager were not always open and transparent with others involved in people’s care. This included failing to acknowledged to people and their representatives when things went wrong, and a continued failure to learn lessons to prevent the same thing happening again. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders told us their governance systems and management of the service were failing. The registered manager told us they struggled to lead the service, and their oversight of quality and safety was not robust. The audits undertaken by the provider and registered manager continued to be poor in every area of quality and safety. When we challenged the registered manager about this, they told us “I cannot do everything…… I was doing spot checks, and I will need to bring those back in again. It’s obviously not sinking in”.

Governance and management of the service continued to be inadequate. There was a continued failure by leaders to take accountability of their performance, and the performance of the staff they managed, and how this impacted the quality of people’s lives, and their safety. Leaders failed to identify through audits that decision specific mental capacity assessments had not been undertaken in relation to decisions that needed to be made. There was no evidence of best interest meetings where restrictions were in place to determine what other least restrictive measures had been considered. Leaders failed to address the repeated concerns around disrespectful, discriminatory and repetitive language used about people in care notes. The registered manager told us they undertook out of hours visits to the service. Despite this, they failed to identify the institutionalised practices. They failed to identify through audits, staff were not following the guidance from health care professionals. Leaders were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service, and people continued to experience poor outcomes because of these failures.

The registered manager told us they always updated the funding authorities and the local safeguarding teams of changes to people’s care and incidents in the home. However, we established this was not always the case. They told us they had contacted external professionals in relation to assisting with people’s communication aids however there was no evidence of this.

External professionals told us they were not always made aware of incidents at the service. One told us that the lack of incident reports to them meant they were not able to review whether the appropriate action was taken or whether the persons’ care needed to be reviewed. They said, “There are delays with incident reporting, (we are concerned) the risk may not be being managed.” They told us they did always have confidence in the leadership team.

The provider and registered manager did not work collaboratively with partners and stakeholders. Because of this, people did not receive the right care when they needed it, and were at risk of receiving unnecessary treatment and restrictions. People did not experience seamless, joined up care, instead, their care was disjointed and inaccurate and avoidable risks were ongoing because of these failures. Leaders were not open or transparent: For example, the registered manager told us they had informed the local authority and social worker of incidents that had occurred with a person in July 2024. However, both the funder and the local authority told us they had not been told. The registered manager told us an external professional had recently advised a person was now not able to walk and needed to remain in their wheelchair during the day. However, when we asked for evidence of this, the guidance from the professionals was from many years ago and did not reflect what the registered manager said. The failure to collaborate, lack of transparency, and unsafe misinterpretation of clinical professional guidance not only meant that people were failed by leaders and staff they put their trust in to keep them safe, but they were at ongoing risk of harm.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.