Care @ Rainbow's End

About the service

Care @ Rainbow’s End is a residential care home providing personal care for up to 5 people with a learning disability. Accommodation is provided over two floors. A communal lounge, and Kitchen with a dining room are based on the ground floor. At the time of our inspection there were 5 people using the service.

People’s experience of using this service and what we found

Right support

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.

Mental capacity assessment had not been carried out robustly by the provider to ensure people were supported to have maximum control of their lives and supported in best interest safely; the policies and systems in the service did not support this practice.

The provider did not have effective processes or systems in place to safeguard people. to ensure they were safe from harm. Staff did not understand when a safeguarding needed to be reported to appropriate bodies.

People were not supported by staff who had been appropriately trained and were competent. People had not received their medicines safely.

Right care

People’s care plans and risk assessments did not cover their range of care and support needs. Staff were not guided to support people in line with legislation, good practice and their training. People had not been protected from harm and abuse.

The provider had not always provided staff with information and guidance to support people who were expressing distress and emotional distressed to ensure people had positive outcomes. Individual risks were not always assessed or managed well, and this placed people at risk.

Right culture

The service was not well-led. There was no effective governance system in place to monitor the quality of the service provided to people. The provider continued to fail to recognise risks and concerns in relation to health and safety, safeguarding, completing records and medicine management.

The provider continued to not follow recruitment legislation and ensure staff deployed had the right employment checks and skills to support people safely.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 9 December 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out our previous unannounced focused inspection of this service on 7 November 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, need for consent, and governance. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of safe, effective, and well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvements to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, and well led sections of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Care @ Rainbow’s End on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to providing safe care and treatment, medicines management, infection control, safeguarding, consent to care, and management of the service at this inspection.

We took enforcement action 19 May 2023 and imposed conditions to the registration.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

About the service

Care @ Rainbow's End is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. On the day of our inspection 5 people were using the service.

People's experience of using this service and what we found

Right Support:

Mental capacity assessments were not always carried out robustly by staff to ensure people’s safety. However, people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

People had a choice about their living environment and were able to personalise their rooms. Staff supported people to take part in activities and pursue their interests in their local area. Staff ensured people had access to specialist health and social care support in the community.

The provider had effective safeguarding systems in place and staff had an understanding of what to do to help ensure people were protected from the risk of harm or abuse.

People were supported by enough appropriately skilled staff to meet their needs. People were receiving their medicines as prescribed.

Right Care:

People were treated with kindness and compassion. During the inspection we observed positive interactions between people and staff.

People's care, treatment and support plans covered their range of needs, however; people's support plans had not identified people’s future goals and aspirations. Nevertheless, staff understood people's needs and the support they required.

Right Culture:

The provider did not always operate effective systems to monitor the quality of the service they provide, including in relation to fire safety and consent to care and treatment.

The provider had not always operated robust recruitment procedures in accordance with government legislation.

People and those important to them, including advocates, were involved in planning their care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 July 2022). The service remains rated requires improvement.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 14 and 20 June 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, consent to care, good governance and staffing.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained the same. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Care @ Rainbow's End on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safety of the environment, consent to care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service

Care @ Rainbow's End is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. On the day of our inspection five people were using the service.

People’s experience of using this service and what we found

Right Support

The provider had not always supported people to have the maximum possible choice and control over their lives and to be independent. Mental capacity assessments and best interest decisions for people who were unable to make specific choices about aspects of their care and support were not always considered in a timely manner.

People who lived at the service attended various specialist colleges during weekdays, however people’s support plans did not always focus on their strengths or provide guidance to promote their independence or teach them new skills.

Staff supported people to take part in activities and pursue their interests in their local area and to interact online with their relatives during the lockdown. People were supported to attend variety of out of service activities, for example people went on a short holiday to a holiday park, swimming pools or music festivals.

People had a choice about their living environment and were able to personalise their rooms. People benefitted from the interactive and stimulating environment. Peoples bedrooms were clean and very person centred, with photographs of their relatives and things that were important to people. People had access to a large and secure garden with equipment, such as swings, trampoline and two hot tubs they could use to support them with sensory needs and relaxation.

Right Care

Staff had not always understood how to protect people from poor care and abuse. We saw one incident between two people which resulted in physical abuse. This was not reported to the local authority safeguarding team. This meant that actions were not always taken to learn from incidents to reduce the risk of reoccurrence.

People’s support plans had not always reflected their range of needs to promote their wellbeing and enjoyment of life. We looked at range of support plans and we found that some support plans were person centred and specific to each person, describing their likes and dislikes or cultural needs. However, there were no plans for other specific aspects of people’s lives for example promoting and encouraging people to complete some daily tasks or supporting people to develop new and build on current their skills.

The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

People who had individual ways of communicating, using body language, sounds or media devices could interact comfortably with staff and others involved in their care.

Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care. People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs

Right culture

People led inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff.

Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. People and those important to them, including advocates, were involved in planning their care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 5 December 2018).

Why we inspected

The inspection was prompted in part due to concerns received about assessing risks to people, capacity assessments and best interest decisions and medicines. A decision was made for us to inspect and examine those risks. Additionally, we undertook this inspection to assess that the service is applying the principles of Right support right care right culture.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to managing risks, medicines, staff training, mental capacity and overall management of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

• Safe arrangements were in place for visitors. This included confirmation of a negative lateral flow test, temperature checks, and the use of personal protective equipment (PPE).

• There were adequate supplies of personal protective equipment (PPE) throughout the home. Risk assessments were in place for residents where the use of PPE, other than masks, was not appropriate. Staff were seen appropriately using PPE.

• There were arrangements to admit people safely to the home. This included testing and isolation in line with guidance. Arrangements were in place to undertake individual risk assessments in the event of a new admission.

• People were supported to understand and comply with visiting and social restrictions in line with all best practice guidance and this was communicated and updated as needed.

• The provider followed relevant COVID-19 testing guidance. This included staff testing requirements as well guidance on testing for people using the service and visitors.

• Maintaining the mental health of people and staff was a priority with proactive support from the service to encourage people’s well-being.

• There were clear cleaning schedules in place which included the frequency of cleaning high touch areas.

• The home had an up to date infection control policy and carried out regular infection control audits.

• Staff were trained and knew how to immediately instigate full infection control measures to care for a person who developed symptoms, who tests positive or who has been exposed to the virus to avoid the virus spreading to other people and staff.

Care at Rainbow’s End is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates seven people. On the day of our inspection seven people were using the service.

The care service had not originally been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. However, people were given choices and their independence and participation within the local community encouraged.

At our last inspection on 3 March 2016 we rated the service ‘good.’ At this inspection we found the evidence continued to support the rating of ‘good’ overall. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People continued to receive a safe service where they were protected from avoidable harm, discrimination and abuse. Risks associated with people’s needs had been assessed and planned for. These included risk assessments of activities people participated in such as horse riding and swimming. Risk assessments were reviewed monthly to ensure they reflected people’s most up to date circumstances. Staff followed the information in people’s risk assessments which ensured that people consistently experienced care and support that was safe.

People did not have any undue restrictions placed upon them and were encouraged to be as independent as possible. They were taught skills that increased their independence and which supported them to achieve longer term goals of living in their own homes.

There were sufficient suitably skilled and experienced staff to consistently meet people’s needs. Safe staff recruitment procedures were in place and used to ensure that only staff who met the services standards worked there. People received their prescribed medicines safely and these were managed in line with best practice guidance. Accidents and incidents were analysed for lessons learnt and these were shared with the staff team to reduce further reoccurrence and protect people from harm.

People continued to receive an effective service. Staff received the training and support that was specific and relevant to people’s individual needs. People were supported with their nutritional needs. People were supported with their needs and accessed health services when required. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The principles of the Mental Capacity Act (MCA) were followed.

People continued to receive care from staff who were kind, compassionate and treated them with dignity and respected their privacy. Staff had developed positive relationships with the people they supported. They had a very good understanding of people’s needs, preferences, and what was important to them. People’s independence was promoted and they were supported to make informed choices about their care and support.

People continued to receive a responsive service that was strongly focused on their unique individual needs. People’s needs were assessed and planned for with the involvement of the person and or their relative where required. People were supported to pursue their interests and hobbies.

There was a complaint procedure in an easy to read format that people could access if they wanted to make a complaint.

The service was managed by a registered manager. They were supporting another staff member who had applied to be the registered manager and who would take over the running of the service.

Further information is in the detailed findings below.

The service did not have a registered manager in place at the time of our inspection. However the manager in post told us they were in the process of applying to become the registered manager but we had not yet received the application. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People who used the service were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The manager shared information with the local authority when needed. Risks to people’s safety was assessed and reviewed regularly. Action was taken following any incidents to try and reduce the risks of incidents happening again. People received their medicines as prescribed and the management of medicines was safe.

Staffing levels were sufficient to support people’s needs and people received care and support when required. Staff were provided with the knowledge and skills to care for people effectively and felt supported by the management team

People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We also found staff were aware of the principles within the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were supported to eat and drink enough. Specialist diets were provided if needed. Referrals were made to health care professionals when needed. People who used the service, or their representatives, were encouraged to contribute to the planning of their care.

People were treated in a caring and respectful way and staff delivered support in a relaxed and considerate manner. Positive caring relationships had developed between staff and the people who lived at the home and different communication techniques were used to assist people to make their needs known.

People who used the service, or their representatives, were encouraged to be involved in decisions about the running of the service and systems were in place to monitor the quality of service provision. People also felt they could report any concerns to the management team and felt they would be taken seriously.

Say when the inspection took place and whether the inspection was announced or unannounced. Where relevant, describe any breaches of legal requirements at your last inspection, and if so whether improvements have been made to meet the relevant requirement(s).

Provide a brief overview of the service (e.g. Type of care provided, size, facilities, number of people using it, whether there is or should be a registered manager etc).

N.B. If there is or should be a registered manager include this statement to describe what a registered manager is:

‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

Give a summary of your findings for the service, highlighting what the service does well and drawing attention to areas where improvements could be made. Where a breach of regulation has been identified, summarise, in plain English, how the provider was not meeting the requirements of the law and state ‘You can see what action we told the provider to take at the back of the full version of the report.’ Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work at there.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Although the service currently had no applications to be submitted for a DoLS order, proper policies and procedures were in place. We saw the appropriate staff understood when an application should be made, and how to submit one.

The manager explained how they would follow the policy to ensure that a person's liberty was not being restricted unlawfully. We saw from training records that most of the staff team had received training in Deprivation of Liberty Safeguards and the Mental Capacity Act 2005, which is legislation designed to help maintain the safety and rights of vulnerable people in care settings.

A relative commented, 'When we leave [our relative] there we don't have to give her wellbeing, safety or happiness another thought and, as a result, have been able to really relax and have a proper time of respite. [X] is always happy to go there and misses being there when [X] leaves.'

Is the service effective?

People were unable to tell us themselves about their experience of the service due to the complexity of their needs but family members told us they thought the service was effective in providing the care their relatives needed.

We spoke with family members of people who used the service for both long stay and respite care.

One person told us, 'The home involves our family in reviews and assessments. Any problems, I can ring the manager or the owner.' Another relative commented, 'The residents are encouraged to participate in activities to the maximum level of their abilities. They are involved in daily activities such as meal preparation and doing the laundry, giving a sense of independence which I consider to be very important. They get out and about which we feel is important for [X]'

We looked at care files and found the service effectively identified individual needs and based care and support programmes upon those needs. The staff respected the equality and diversity of the people who used the service by making sure the care, facilities and nutrition were provided individually to each person's needs.

Is the service caring?

We saw staff supporting people in a caring manner and responded to individual needs in a patient and dignified way. We saw members of staff talking with people and using their knowledge of the individuals to respond to their wishes.

One relative told us, 'The positives we have found are that Rainbows End has a very homely feel. Numbers are such that it feels like you are visiting family and, particularly so, as the owner and the staff are so welcoming and there is a warmth and understanding from all the staff we have had contact with. The rooms are just like being at home, none of the 'hospital ward' or 'care home' type rooms.'

Is the service responsive?

The manager, owner and staff at the home met with people before they used the service to identify if the service could meet their needs. This process included consulting with family members and carers, as well as professionals such as doctors and physiotherapists to plan the best way of meeting people's needs. This multi-agency approach then continued to support the ongoing care of each person at the home.

A member of staff told us they always consulted people to make sure the service was right for them before arranging for them to stay. A relative of a person who used the service told us, 'We requested respite care for our relative at short notice due to a family emergency, and they were able to offer him care on the day we contacted them.'

Is the service well-led?

Other professionals who supported people living at the home told us the manager had made great efforts to improve the service offered at the home. Staff members reflected how they had benefitted from positive and supportive leadership within the service.

A relative of a person who used the service commented, 'I have nothing but praise for the quality of Care@Rainbow's End since our relative left our home. Any problems or issues are dealt with within 48 hours.'

Another relative told us, 'The manager is very approachable and at the same time professional. When we first made contact they were extremely welcoming and took time to explain the set up at Rainbows End and encouraged us to visit or contact her whenever we wished.'

There were systems in place to protect people from abuse or the risk of abuse and relationships between staff and the people who used the service were relaxed and friendly. However, more needed to be done to improve the communication systems to report abuse.

The environment was comfortable and spacious but risks had not been appropriately assessed and managed so that people were adequately protected. In addition, the registered provider needed to ensure that they met their obligations to report significant events to the Care Quality Commission.

We were told by one person who used the service that they liked living at the home. Visitors also told us that living at Care@Rainbow's End had been a positive experience for their relative. Our evidence supported what people told us. People who used the service were helped by staff who showed a clear understanding of the principles of person centred care and what this looked like in practice. The staff had the right competencies, knowledge, skills and experience to meet people's needs or we saw that arrangements had been made for them to develop these.