Care @ Rainbow's End

Inspectors found the environment homely, with people's bedrooms personalised using belongings that mattered to them.

“The environment was homely. People had personalised their own bedrooms.” from the report

People who needed eating and drinking aids were observed using them, and staff supported people with meals in a caring and dignified way.

“People who required support with their meals were supported in a caring and dignified way by staff.” from the report

Risks were not consistently assessed or managed. Fire safety and hot water concerns from the previous inspection were still present.

“This meant people were not safe and were at risk of avoidable harm.” from the report

Staff physically moved people during some incidents without robust processes, suitable guidance or evidence of multi-agency agreement. Possible abuse and restraint incidents were not always reported.

“A person had been subject to physical restraint by staff without robust processes and procedures being in place to enable that to happen safely.” from the report

Some medicines lacked the instructions and records staff needed. Medicines were also not stored securely because keys were left beside cupboards and the room was accessible to residents.

“Medicines cupboard keys were observed to be left next to the medicine cupboards.” from the report

Not all staff had training in areas such as communication, mental capacity, oxygen therapy, stoma care and positive behaviour support. Competence checks were incomplete.

“This left people at risk of being supported by staff without the skills to meet their needs effectively.” from the report

The home and equipment were visibly dirty. Bathrooms had limescale and mould, and cleaning schedules were not completed or effectively checked.

“The home and people's equipment were visibly dirty and unclean.” from the report

Care plans lacked important details and sometimes conflicted with each other. Decision-specific mental capacity assessments were missing for areas including covert medicines, finances and personal care.

“Decision- specific mental capacity assessments had not been completed for all decisions where people's capacity was in doubt.” from the report