CQC report explained · a residential care home
What the CQC found at Rayleigh House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable staffing, safe medicines management, appropriate risk assessments and good safeguarding arrangements. They noted that consent for CCTV was not documented in all cases.
- Effective?
- Good
- Staff understood people's health needs, received relevant training and supported people to eat, drink and access healthcare. Some improvements were agreed, including checking that people were shown meal choices and improving signs for the dining area.
- Caring?
- Good
- Staff were warm, patient and respectful. People had personalised rooms, were involved in care decisions and said they felt relaxed and at home.
- Responsive?
- Requires improvement
- Care plans did not always record the detailed, person-centred information that staff knew. Activities were enjoyed, but people and relatives wanted a wider and more personalised range, and the activities planner was empty.
- Well-led?
- Good
- The registered manager and staff worked well together and had strong relationships with outside professionals. The management team responded positively to the improvements identified during the inspection.
What inspectors found, September 2019
Rated Good overall; inspectors found kind, safe care, but the Responsive rating was Requires Improvement because care records and activities needed work.
This was an unannounced inspection on 4 September 2019. The inspectors spoke with people living at the home, relatives, staff and health and social care professionals. They also checked care plans, risk assessments, medicines records, training, policies, meetings and maintenance records.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found safe medicines management, suitable staffing, clean and well-maintained premises, knowledgeable staff and warm, respectful care. People were involved in decisions about their care and had access to healthcare.
Responsive was rated Requires Improvement. Care plans had been reordered but did not yet contain all the detailed, person-centred information staff knew about people's needs. People enjoyed activities, but inspectors found that more could be done to offer a wider and more personalised range.
The overall rating remained Good, the same as at the previous inspection. However, the Responsive rating had fallen from Good to Requires Improvement.
Safe medicines
Medicines were managed safely, with effective and consistent stock checks. Staff showed a good understanding of people's needs.
“Medicines were managed safely, in line with best practice.” from the report
Kind and homely care
Inspectors saw warm and respectful interactions. People described the home as relaxed, personal and welcoming.
“The home felt welcoming, personalised and vibrant. Feedback was positive regarding the compassionate, affectionate and sensitive approach of staff.” from the report
Staff knowledge
Staff understood people's health, physical and emotional needs and used this knowledge to support them.
“They know people so, so well and aren't afraid to ask for advice. Whenever we go the staff know everything about the person.” from the report
End of life care
Staff had relevant training and the home had links with external professionals. Inspectors said this was a key strength recognised by outside professionals.
“End of life care was regarded as a key strength by external professionals.” from the report
Strong teamwork
Inspectors found low staff turnover, good morale and a supportive relationship between the manager and staff.
“Staff turnover was low and morale good. The registered manager interacted well with all members of staff and we observed instances of strong teamwork.” from the report
Care records needed updating
needs fixingThe care plans had been put into a clearer order, but they did not always include the detailed personal information that staff knew about people's needs and preferences.
“Whilst staff demonstrated a comprehensive knowledge of people's needs and preferences, care plans did not always reflect this.” from the report
Activities were not personalised enough
needs fixingPeople enjoyed activities such as gardening and baking, but people and relatives said more should be done to match activities to individual interests. The activities planner was empty at the inspection.
“There was a consensus of opinion from people we spoke with and relatives that more effort could be made to personalise the range of activities available.” from the report
CCTV consent records
minorPeople and relatives were happy with CCTV in communal areas, but consent had not been documented in every case. The owner agreed to include this in pre-admission questions.
“All people and relatives we spoke with were happy with this, although the owner had not documented this consent in all cases.” from the report
- 01How have you updated care plans so they include detailed, person-centred information about each person's needs and preferences?
- 02What activities are available now, and how do you match them to each person's interests?
- 03How do you make sure the activities planner is kept up to date?
- 04How is consent for CCTV recorded for every person living at the home?
- 05How do you check that people are offered meaningful choices of meals and snacks?
This was an unannounced inspection that looked at both the care provided and the premises, and covered all five CQC key questions. This explanation was written from the published report of 27 September 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.
What inspectors found, March 2017
Rated Good; inspectors found safe, kind and personalised care, with a few minor issues addressed during or after the visit.
Inspectors visited without notice on 22 February 2017. They spoke with people living in the home, relatives, staff, managers and the cook. They observed care and checked care records, medicines, staff training, recruitment files and quality checks.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines arrangements, suitable training, respectful care and activities based on people's interests.
A few issues were identified. There was no separate medicine refrigerator, privacy arrangements could have been insufficient in two shared rooms, and written information about advocacy was limited. The home took action on these points, including buying a refrigerator and two privacy screens.
Enough staff
Inspectors found enough staff to meet people's needs without rushing. The home had an established team and did not need agency staff to cover vacancies.
“There were enough staff on duty and background checks had been completed before new staff were employed.” from the report
Respectful care
Staff knew people well and treated them kindly. Inspectors saw that people's dignity, privacy and choices were respected.
“Staff respected people's right to privacy and promoted their dignity.” from the report
Personalised activities
People were supported to keep up their interests and take part in individual and group activities, including outings and contact with relatives.
“People had been fully supported to enjoy a range of hobbies and interests.” from the report
Food and health support
People had access to food and drinks and received support that reflected their dietary needs and preferences. Staff also helped people attend healthcare appointments.
“People were supported to eat and drink enough to keep them healthy.” from the report
Visible leadership
The registered manager and provider worked closely together. They used audits, feedback and care reviews to monitor the service.
“The provider and registered manager worked closely together and completed regular quality audits and checks to help ensure that people received appropriate and safe care.” from the report
Medicine refrigeration
needs fixingThe home did not have a separate refrigerator for medicines that might need to be kept cold. The provider confirmed after the inspection that a refrigerator had been bought and fitted.
“We did however note the home did not have a separate refrigerator for storage of medicines which might need to be refrigerated.” from the report
Privacy in shared rooms
needs fixingTwo rooms were shared. Inspectors were concerned that one privacy screen might not be enough if both rooms needed personal care at the same time. Two more screens were bought immediately.
“However, we were concerned that if the screen was needed at the same time for both rooms' people's privacy may be compromised.” from the report
Advocacy information
minorThere was limited written information about independent advocacy and how to contact an advocate. The information was updated and made available during the inspection.
“We noted there was limited accessible written information available within the home regarding lay advocacy organisations and how people could access these.” from the report
Audit records
minorSome audit information was not initially easy to locate. The manager said limited time for administration was an issue, and the provider reviewed how to support the management team.
“We noted that some of the audit information we asked to see was not initially easy to locate.” from the report
- 01How are medicines that need refrigeration stored now, and when was the new refrigerator last checked?
- 02How do you protect privacy when people in both shared rooms need personal care at the same time?
- 03What written information can residents and families see about independent advocacy?
- 04How are complaints recorded, investigated and followed up, given that there had been no formal complaints at the inspection?
- 05How do you make sure care audits and other management records are completed and easy to locate?
This was an unannounced inspection covering all five questions and the overall quality of the home; it was the first inspection since the provider changed its registration status. This explanation was written from the published report of 22 March 2017 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 Rayleigh House
2 rated inspections over 3 years: the service has held its Good rating throughout.
- September 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016
Registered with the Care Quality Commission on 7 September 2016.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.