CQC report explained · a nursing home
What the CQC found at Rawreth Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that 11 people had missed some medicines because they were unavailable or out of stock. Risk assessments and moving and handling practice were also not always safe, although staffing, recruitment and infection control arrangements were suitable.
- Effective?
- Requires improvement
- The home did not consistently follow the Mental Capacity Act or use the least restrictive approach. Staff training was not embedded in daily practice, and people's nutrition and hydration were not always properly supported or monitored.
- Caring?
- Requires improvement
- People were not always treated with dignity or respect, including during meals and through the use of the same plastic beakers and cutlery for everyone. Most relatives and some people nevertheless described staff as kind and caring.
- Responsive?
- Requires improvement
- Care plans did not always contain current, personalised information about people's dementia, mental health, communication or end-of-life needs. People did have access to activities, family visits and healthcare services.
- Well-led?
- Inadequate
- Governance and quality checks did not reliably identify or correct problems. Inspectors found that lessons had not been learned and that several breaches from the previous inspection continued.
What inspectors found, November 2023
Overall Requires Improvement; inspectors found unsafe medicines practice and care shortfalls, while well-led was rated Inadequate.
This was an unannounced inspection in September 2023. Inspectors visited on three days, spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management information.
The home had enough staff on duty and recruitment checks were completed. Infection prevention arrangements were suitable, people could receive visitors, and staff worked with health professionals. Relatives and most people also described care as kind.
However, inspectors found missed medicines, unsafe moving and handling, incomplete risk assessments, poor monitoring of nutrition and fluids, and care records that were not always accurate or complete. People were not always treated with dignity, and some restrictions were imposed without the required consent or best-interest decisions.
The overall rating remained Requires Improvement, as it had been in 2019. Safe, effective and responsive also remained Requires Improvement. Caring fell from Good to Requires Improvement, while well-led fell from Requires Improvement to Inadequate. The provider was still in breach of regulations from the previous inspection.
Infection control
The home had suitable arrangements for preventing and managing infection, with enough protective equipment available.
“We were assured the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Activities and relationships
People took part in group and one-to-one activities, and staff supported relationships with family and friends.
“People were observed to participate in group activities and to receive one to one support.” from the report
Medicines were not always safe
seriousEleven people missed some medicines because supplies were unavailable. Inspectors also saw errors in administration, insecure storage and incomplete medicines information.
“We found 11 people had missed some of their medicines between 23 August 2023 and 7 September 2023, as these were either not available or out of stock.” from the report
Risks were not properly assessed
seriousSome risks were not recorded or did not explain how staff should reduce them. Inspectors also saw unsafe moving and handling.
“Arrangements were not robust to manage and mitigate risk for people using the service.” from the report
Restrictions and consent
seriousBathroom and toilet doors were locked, and bedroom door alarms continued to be used without recorded consent or best-interest decisions. Some DoLS applications were also not renewed on time.
“We identified signs of a 'closed culture' whereby blanket restrictions were imposed and were not the least restrictive option.” from the report
Nutrition and hydration
seriousDrinks and snacks were not always freely available, people's fluid intake was not properly recorded, and one person was rushed while eating.
“Staff did not ensure people's hydration levels were maintained in line with their assessed needs.” from the report
Dignity during care
seriousPeople were given the same plastic beakers and cutlery without enough attention to individual dignity. Staff were also seen standing while helping people eat instead of sitting at eye level.
“People were not always treated with respect and dignity.” from the report
Poor oversight and care records
seriousAudits and governance systems did not identify or resolve repeated problems. Care plans were incomplete, inaccurate or out of date.
“The lack of effective oversight and governance of the service at both provider and service level, has resulted in several continued breaches of regulation.” from the report
- 01What action has been taken to ensure medicines are always available, correctly administered, securely stored and accurately recorded?
- 02How are individual risks now assessed and recorded, including moving and handling, distress, fire evacuation and medicines?
- 03How do you check that restrictions such as locked doors or alarms are lawful, individually assessed, consented to or made in the person's best interests?
- 04How are people's food and drink choices, fluid intake and safe eating now monitored?
- 05What changes have been made to care plans and quality audits since the warning notices, and how will you show that these changes are working?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, after the previous Requires Improvement rating published in 2019. This explanation was written from the published report of 10 November 2023 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, March 2019
Rated Requires Improvement; inspectors found kind, person-centred care but serious gaps in safety, care planning, staffing and oversight.
This was the home’s first inspection since it was newly registered. Inspectors visited without notice on 21 and 22 November 2018. They spoke with people, relatives and staff, reviewed care and staff records, and checked medicines, staffing and quality systems.
Inspectors found that people were treated kindly and received person-centred care. Healthcare, food, drinks and activities were generally provided well. Families said they were positive about the staff and care.
However, risks were not always assessed properly. Medicines were not always recorded or stored safely, staffing levels were sometimes short, and care plans did not give staff enough guidance. The home did not always follow the rules about consent and restrictive practices.
The overall rating of Requires Improvement means the home was not consistently meeting the standards expected. Five regulations were breached, and the provider was asked to set out what it would do to improve.
Kind relationships
People and relatives spoke positively about the care. Inspectors saw staff treating people with kindness, compassion and respect.
“We observed that staff were friendly, kind and caring towards the people they supported.” from the report
Person-centred support
Staff knew people well, understood their communication needs and encouraged them to do what they could for themselves.
“Our observations showed that people received person-centred care and they had a good rapport and relationship with the staff who supported them.” from the report
Meals and hydration
People received enough food and drink. Mealtimes were calm and staff helped people sensitively when needed.
“Mealtimes were seen to be relaxed, friendly and unhurried.” from the report
Medicines records and storage
seriousInspectors found several discrepancies in medicines records. Medicines were left unsecured, and guidance and records for medicines given when needed were not always available or complete.
“Not all medicines were securely stored.” from the report
Unidentified safety risks
seriousSome people's risks, including falls risks, were not fully recorded or managed. Staff did not always have clear instructions about the support required.
“Not all risks to people's safety and wellbeing had been identified, and suitable control measures had not always been considered and put in place to mitigate the risk or potential risk of harm for people using the service.” from the report
Staffing shortfalls
seriousStaff deployment was usually suitable, but staffing levels were not always maintained. This meant planned two-to-one support was sometimes not provided and an appointment was delayed.
“The daily care records for one person recorded that following an incident whereby they had become distressed resulting in being a risk to themselves and others, they were scheduled to receive 2:1 supervision from staff.” from the report
Consent and restrictions
seriousThe home did not always record people's capacity, best interests or consent when restrictive measures were used. Inspectors were concerned that some arrangements were not shown to be least restrictive or legally authorised.
“Staff demonstrated limited understanding of the Mental Capacity Act [MCA] 2005 and Deprivation of Liberty Safeguards [DoLS].” from the report
Incomplete care plans
seriousCare plans did not give enough detail about mental health, behaviours, dementia-related needs or end of life care. This could leave staff without the information needed to provide consistent support.
“Care plans did not fully reflect people's holistic care and support needs or provide sufficient guidance for staff as to how these were to be met.” from the report
Weak quality checks
seriousThe home's audits and monitoring systems did not identify the problems found during inspection. This meant managers did not have effective oversight of important risks and shortfalls.
“These systems did not identify the issues we identified during our inspection.” from the report
- 01What changes have been made to medicines storage, MAR records and protocols for medicines given when needed?
- 02How are falls and other safety risks now assessed, recorded and shared with all staff?
- 03How do you make sure planned two-to-one support is provided when people need it?
- 04How do you record capacity, best interests and consent before using bedrails, alarm mats or locked and alarmed bedroom doors?
- 05Have all care plans, including mental health and end of life plans, been reviewed and updated?
This was an unannounced first inspection since registration and covered all five key questions, including accommodation and personal care. This explanation was written from the published report of 9 March 2019 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 Rawreth Court
2 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017
Registered with the Care Quality Commission on 31 March 2017.
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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