Rainscombe House

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• 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 remained inadequate. This had a significant impact on the quality and safety of the service people received. Despite a number of audits and monitoring systems in place these were ineffective as shortfalls had not been identified. Information about risks, performance and outcomes were not used effectively to improve care. Partnership working was poor, and leaders failed to ensure guidance was followed, or ensure learning was embedded. Learning from previous inspections had not been learnt from or robustly shared with staff to help ensure staff followed good practices at all times. Although staff felt things had improved because they felt more supported, we found the culture within the service from senior management was still poor. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 and staff continued to demonstrate no insight into the organisational culture of the service. There was a closed culture at the service which impacted on every aspect of people’s lives. The registered manager told us, “In my mind I envisage a good service where people are happy and settled.” However, leaders and staff lacked skills, understanding, knowledge and values to ensure there was a shared vision, strategy and culture which centred around people. Staff said they felt better supported by the new registered manager and that morale had improved. However, we found staff and leaders failed to understand their roles. People and their representatives were not involved in meaningful collaboration with leaders or staff. People’s human rights were not always upheld, and people did not receive safe, high quality or compassionate care.

Processes to ensure there was a shared direction and culture which was embraced by all staff and leaders were inadequate. Leaders had failed to have a clear shared vision and strategy for the service. They did not lead by example, or ensure that staff had a good understanding of how critical their roles in carrying out the vision and strategy are in ensuring people led lives of their choosing, and did so in a way which they were supported and empowered. Leaders did not demonstrate a positive, compassionate listening culture. Despite the registered manager using reflective practice, supervisions and staff meetings to help improve staff understanding and practices, these were not successful: they did not bring about the significant changes in staff practice needed to ensure people were at the heart of the service, and received safe, high quality and compassionate care.

Leaders continued to lack the capability, skills, knowledge and credibility to lead effectively. We spoke with the registered manager about their vision for the service, they were unable to talk knowledgeably about a clear vision, but told us about their views regarding the staff. They said, “I can see the good in the staff and I know they have the skills and the knowledge. I have worked hard with them and they talk to me and approach me now.” The registered manager and provider did not recognise the closed culture at the service, or recognise their lack of knowledge or robust action in addressing the culture impacted on staff and people. The service was not inclusive, leaders failed to take accountability or action to improve this. Staff told us they had regular staff meetings. A staff member said, “We do it altogether. We talk about the activities we will do with the clients. If there is an issue we can address it. We also discuss accidents and incidents.” Despite this feedback, there continued to be significant issues of concern.

Processes to ensure leaders and staff had the skills and capabilities to consistently deliver an inclusive service in which people received safe care and treatment were inadequate. Although staff told us they felt morale was better within the staff team and that they felt supported we read a supervision record between the provider and one staff member which did not demonstrate an inclusive or compassionate approach. The record which related to the staff member completing their training was punitive in tone and did not offer support or time for the staff member to complete their training during working hours.

The registered manager said when they first started at the service they held a team meeting to remind staff on speaking up. They told us, “I did an easy-read safeguarding guide for staff and reminded them who they could speak with in the organisation and outside if they had concerns.” They sent us this guide however we saw it was the Surrey Safeguarding Adult board leaflet and not a personalised one to staff at Rainscombe House.

Staff had access to a safeguarding and whistleblowing policy should they have any concerns. Some staff had felt confident to contact CQC directly to report their worries. Yet staff were not ensuring they were keeping contemporaneous records which would protect people from potential abuse.

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.

We spoke with staff about training, monitoring and taking action in response to issues identified. We spoke with one staff member about the lack of action in response to the high medicines cabinet temperature and found, despite being trained in medicines, they had little understanding of checking the minimum and maximum temperatures and what this meant. This demonstrated the provider’s systems and monitoring arrangements were not robust enough as staff were unaware of good practices. In addition, this staff member carried out medicine competency checks on other staff which meant there was a risk because senior management had not ensured through their governance arrangements that staff were fully trained, to help ensure poor practices were not being transferred to other staff.

Governance and quality monitoring systems were inadequate. Audits and monitoring were undertaken by senior management but these were not robust. For example, the unsafe back garden, high temperature of the medicines cabinet and the poor infection control practices. There were discrepancies in mileage and daily expenditure records which had been signed off by a compliance manager as correct. Mileage records showed the mileage clock at a different starting point to that of the finishing point on 3 occasions over an 8-week period. It also showed large numbers of miles for local journeys. For example, towns approximately 5 miles away, showed mileage of between 35 and 55 miles. Medicines audits for the last 2 months noted ‘yes’ beside the question ‘Do staff know what to do if medication room temperature exceed 25 degrees’ and yet we found this was not the case. The last pharmacy audit was May 2023 which meant the registered manager had not involved professionals to check their medicines practices were safe. Daily notes continued to contain poor spelling, the wrong gender used and entries out of order. This meant care notes were difficult to read and may be inaccurate. Our observations during the assessment identified that daily records were not a truthful account of how people spent their days. The registered manager did a monthly manager oversight audit covering all aspects of the service. They had recorded they had obtained feedback from one person on how happy they were at the service, but stated the other two people were ‘non- verbal and do not use Makaton’. However one person did use Makaton. They also completed daily external checks. Despite this, they had not identified the safety issues in the back garden.

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

The registered manager told us they had implemented improvements at the service, and described an increase in some activities for some people. They had not recognised the the continued failure to learn, improve and innovate. Leaders did not have a clear strategy for improvement, despite telling us about ‘reflective practice’, learning from incidents was poor, and leaders had failed to identify significant issues in the service around people’s choice, safety and well being.

Processes to ensure learning, improvement and innovation were inadequate. The registered manager and staff had not learned from shortfalls we found at previous assessments. There continued to be a theme of poor and unsafe care for people as leaders were not consistent in their oversight. People continued to be put at risk. For example, we had previously identified risks associated with people being given inappropriate foods, at this assessment we identified the same concerns. Despite the introduction of keyworkers, there was no apparent benefit to people. There was no evidence keyworkers worked with people to achieve goals or aspirations, there was no record of regular meetings or aims and objectives of having this system in place. We noted some people’s keyworkers were staff who worked night shifts. The provider had introduced an electronic system which enabled staff to record daily handovers, daily checks and other important information which could be easily viewed and audited by senior management. We were told by a staff member that all staff had been trained in the new system, however we found this was not the case as when they sent us the records it showed only 3 of the 7 staff who regularly worked at the service had received training.