Rawreth Court

Updated 10 November 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by 3 inspectors, one of whom was a specialist pharmacist inspector, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Rawreth Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Rawreth Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 5 September 2023 and ended on 21 September 2023. We visited the location’s service on 5, 7 and 21 September 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the Local Authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people who use the service and 7 relatives about their experience of Rawreth Court. We spoke with the registered manager and 7 members of staff, including nursing and care staff. We also spoke with an activities coordinator, a physiotherapist, the operational service manager and Clinical Lead for Compliance. We reviewed a range of records. This included 13 people’s care records and people’s medication administration records. We looked at 4 staff files in relation to recruitment, training, and supervision. A variety of records relating to the management of the service, quality assurance information and policies and procedures were viewed.

Updated 10 November 2023

About the service

Rawreth Court is a residential care home providing the regulated activities of accommodation, personal and nursing care to up to 35 people. The service provides support to older people living with dementia and who may also be living with mental health needs. At the time of our inspection there were 34 people using the service.

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

The delivery of care for people was not always safe. Information relating to people's individual risks was not always recorded. Suitable arrangements were not in place to ensure the proper and safe use of medicines. Lessons were not learned, and improvements made when things went wrong.

Staff training was not embedded in their everyday practice. We have made a recommendation about staff training. People at risk of poor nutrition and hydration were not properly monitored to ensure their fluid intake met their needs. People were not always treated with dignity and respect. 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; the policies and systems in the service did not support this practice.

Not all care plans contained enough information to ensure staff knew how to deliver appropriate person-centred care and treatment based on people's needs and preferences. Where information was recorded this was not always accurate or up to date. The leadership, management and governance arrangements did not provide assurance the service was well-led, that people were safe, and their care and support needs could be met. There was a lack of understanding of the risks and issues and the potential impact on people using the service.

Staffing levels and the deployment of staff were suitable. Recruitment practices at the service were safe. Most people and their relatives told us they or their family member were treated with care and kindness. People were supported or enabled to take part in regular social activities. People were protected by the prevention and control of infection. Staff had received an induction and formal supervision. The service worked with other organisations to ensure they delivered joined-up care and support and people had access to healthcare services when needed.

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 March 2019].

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

This inspection was prompted by a review of the information we held about this service and to follow up on action we told the provider top take at the last 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.

Enforcement and Recommendations

We have identified breaches in relation to consent, restrictive practices, risk, medicines management, nutrition and hydration, dignity and respect, care planning and quality assurance arrangements at this inspection. We have made a recommendation about staff training.

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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will also 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.