CQC report explained · a residential care home
What the CQC found at Care @ Rainbow's End
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2024
Rated Inadequate and placed in special measures; inspectors found people at risk from unsafe care, poor oversight and gaps in staff training.
Inspectors visited on 16, 17 and 25 May 2023. The first visit was unannounced. They observed care, spoke with staff, relatives and professionals, and checked care records, medicines, staff files and management records.
They found serious and widespread problems. Risks were not managed properly, medicines were not always given or stored safely, and the environment was dirty. Some people were restrained without suitable plans, training or safeguards. Staff did not always recognise or report possible abuse.
Care plans were incomplete or conflicting. Staff did not always follow health and dietary guidance, including guidance designed to reduce choking risk. Mental capacity assessments and best-interest decisions were not completed properly.
The home was rated Inadequate overall, and Safe, Effective and Well-led were also rated Inadequate. Caring and Responsive were not inspected in this visit, so their earlier ratings were used in the overall rating.
Personalised surroundings
Inspectors found the environment homely, with people's bedrooms personalised using belongings that mattered to them.
“The environment was homely. People had personalised their own bedrooms.” from the report
Dignified meal support
People who needed eating and drinking aids were observed using them, and staff supported people with meals in a caring and dignified way.
“People who required support with their meals were supported in a caring and dignified way by staff.” from the report
People at risk of avoidable harm
seriousRisks were not consistently assessed or managed. Fire safety and hot water concerns from the previous inspection were still present.
“This meant people were not safe and were at risk of avoidable harm.” from the report
Unsafe restraint and safeguarding
seriousStaff physically moved people during some incidents without robust processes, suitable guidance or evidence of multi-agency agreement. Possible abuse and restraint incidents were not always reported.
“A person had been subject to physical restraint by staff without robust processes and procedures being in place to enable that to happen safely.” from the report
Medicines not safely managed
seriousSome medicines lacked the instructions and records staff needed. Medicines were also not stored securely because keys were left beside cupboards and the room was accessible to residents.
“Medicines cupboard keys were observed to be left next to the medicine cupboards.” from the report
Staff lacked essential skills
seriousNot all staff had training in areas such as communication, mental capacity, oxygen therapy, stoma care and positive behaviour support. Competence checks were incomplete.
“This left people at risk of being supported by staff without the skills to meet their needs effectively.” from the report
Poor cleanliness
needs fixingThe home and equipment were visibly dirty. Bathrooms had limescale and mould, and cleaning schedules were not completed or effectively checked.
“The home and people's equipment were visibly dirty and unclean.” from the report
Care plans and consent were incomplete
seriousCare plans lacked important details and sometimes conflicted with each other. Decision-specific mental capacity assessments were missing for areas including covert medicines, finances and personal care.
“Decision- specific mental capacity assessments had not been completed for all decisions where people's capacity was in doubt.” from the report
- 01What conditions has CQC placed on the registration, and what evidence can you show that each condition is now being met?
- 02How are medicines now stored, recorded and administered, including covert and as-needed medicines?
- 03What training and competency checks have all staff completed for restraint, Makaton, oxygen therapy, stoma care and positive behaviour support?
- 04How are mental capacity assessments and best-interest decisions now completed and reviewed, including for covert medicines and personal care?
- 05How are care plans, incidents, safeguarding concerns, cleaning and daily records checked by someone independent enough to identify problems?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 16 May 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Care @ Rainbow's End rated Requires Improvement; inspectors found fire safety, consent and oversight problems, although care was kind and medicines were given as prescribed.
This was an unannounced focused inspection on 7 November 2022. One inspector reviewed information, spoke with the registered manager and team leader, observed care, and checked records for four people, medicines records and other management records.
The home remained rated Requires Improvement. Safe, effective and well-led were all rated Requires Improvement. Inspectors found serious problems with fire safety, including faulty fire doors, errors on the fire panel and a lack of regular fire drills. Some hot water was also too hot, creating a scalding risk.
There were also gaps in mental capacity assessments and best-interest decisions. The home’s systems for checking quality, reviewing incidents and keeping records up to date were not effective. However, people were treated kindly, there were enough staff, infection control was satisfactory, and medicines were being given as prescribed.
The home had been rated Requires Improvement at the previous inspection, published in July 2022. The report says it remained in breach of regulations despite the provider’s action plan. The provider was asked to submit a further action plan and CQC said it would continue to monitor progress.
Kind relationships
Inspectors saw positive interactions. People appeared relaxed and comfortable with staff and asked them for help without hesitation.
“People were treated with kindness and compassion. During the inspection we observed positive interactions between people and staff.” from the report
Medicines
Medicines records had been reviewed and replaced. Medicines were stored securely, checked regularly and given as prescribed.
“People received their medicines as prescribed. Medicines were stored securely, stock checked regularly and kept at a safe temperature.” from the report
Enough staff
There were enough staff, including staff to provide one-to-one support for activities and outings.
“There were enough staff, including for one-to-one support for people to take part in activities and outings how and when they wanted.” from the report
Health support
Staff worked with healthcare professionals and supported people to attend routine health appointments and screening.
“People's health conditions were well managed, and staff engaged with external healthcare professionals, for example, GP's and speech and language therapists.” from the report
Fire safety
seriousThe fire panel showed 10 errors, three fire doors were defective and staff had not taken part in regular fire drills. These problems increased the risk of harm if there were a fire.
“During our visit we identified the fire panel displayed 10 different errors, which meant the fire prevention system was not working correctly.” from the report
Consent and mental capacity
seriousDecision-specific capacity assessments and best-interest decisions were missing for some people, including decisions about medicines, finances and consent to care.
“People who lacked mental capacity to make specific decisions for themselves, for example about their medicines, finances or consent to care and treatment did not have comprehensive capacity assessments and best interest decisions in place.” from the report
Weak oversight
seriousThe home did not have effective systems to review support plans, daily notes, accidents and incidents. This meant lessons were not consistently used to prevent problems happening again.
“Effective systems to review people's support plans, daily notes, accidents and incidents had still not been implemented.” from the report
Recruitment records
needs fixingSome recruitment records, including DBS certificates and references, were missing for longstanding staff during the inspection. The provider supplied outstanding DBS certificates on the second day.
“At this inspection the missing documents were still not obtained and put in place for longstanding staff.” from the report
- 01Have the fire panel errors and three defective fire doors now been fully repaired, and what evidence can you show?
- 02How often are fire doors checked and fire drills carried out now?
- 03Have decision-specific mental capacity assessments and best-interest decisions been completed for every person where needed?
- 04How are you now reviewing accidents, incidents, daily notes and support plans to make sure lessons are acted on?
- 05What checks confirm that recruitment records, including DBS certificates and references, are complete for all staff?
This was a focused inspection of Safe, Effective and Well-led, with infection prevention and control also considered; the report says ratings for the other key questions were carried over from the previous inspection. This explanation was written from the published report of 9 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Care @ Rainbow's End
5 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- May 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: GoodResponsive: GoodWell-led: Inadequate
- December 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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