Rayners Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of a legal regulation relating to safe care and treatment.
 

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a positive culture regarding learning from events to prevent harm to people. Lessons were not always learnt to continually identify improvements and ensure good practice.

We found some records of accidents and incidents did not highlight emerging trends to follow up on. However, post assessment, we learnt individual issues were explored with external professionals and actions put in place to keep people safe.

The provider had recently established weekly systems to keep staff up to date with changes in people’s requirements to ensure their needs were met.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Systems were in place to ensure people were assessed prior to living at the home. Staff had access to information about people when emergency services were called. On admission to hospital, staff kept in touch to support a safe discharge back to the service.

We saw visiting professionals supporting people and providing information for care staff. We received positive feedback from professionals who worked with the service.

A visiting professional told us “Staff are very diligent and are on top of concerns regarding people. I know when they are bringing concerns, it is something that needs to be taken care of”.

One relative told us “All thingsconsidered, everything has gone very well since they moved here. I see that they (staff) are all good and they treat my (relative) very well and I have to say they treat me very well too”.

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider always shared concerns quickly and appropriately.

People told us they felt safe and the staff supported their safety. One person told us, “Yes, I feel safe, I have no worries at all”.

People did not express any concerns about their care. They told us staff responded promptly when they pressed their call bell, for example, if they had a fall. One person told us, “I do have a bell, I do use it sometimes, but I try not to overuse it. Someone always comes along”.

Staff had received training on how to protect people from abuse and demonstrated a good understanding of how to recognise it and safeguard people. Staff told us they would not hesitate to raise concerns to the registered manager, and to external parties if needed. We found people and staff had access to information about how to raise safeguarding concerns.

Reporting procedures were understood as was the procedure in the event of incidents, in particular managing a fall. Some shared their experience of highlighting risk and awareness of how risk can be minimised such as changes in a person’s ability to drink independently.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA.

There was some misunderstanding from staff about when a DoLS should be applied for and who needed one. We have provided some clarification about this. However, restrictions placed on people had been done so lawfully. For instance, where people were provided with bed rails, sensor mats or lap belts on wheelchairs to promote their safety. Best interests’ decisions were in place when people lacked mental capacity to make them for themselves.

The provider did not demonstrate they always managed risk to people well.
People and their relatives told us they felt safe at the home with comments including, “I certainly do feel safe living here. I say that because I know that my life would be far more difficult if I was still living in my own home.”

Individual risk assessments were in place to protect people when receiving care and support. Systems were in place to assess and monitor risk to mitigate harm, however, these were not always effective.

Risks had not been effectively identified in the management of diabetes. This was because care plans did not identify how people could manage their blood sugar levels or how to recognise signs of imbalance.

However, we found no evidence people had been harmed.

People were assessed for risks such as skin damage, malnutrition, and falls. When risks were identified, care plans provided guidance for staff on how to reduce the risks.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff had completed moving and handling training though we saw competence assessments records were not up to date.

Falls risk assessments were in place. These included actions to minimise the risk of harm when people wished to access the local community independently.

We found processes had been put in place to enable one person to continue to access the garden following a significant injury sustained during a fall. The registered manager explained the person received discreet staff support and supervision while enabling them to maintain their independence and freedom within their environment.

Staff told us they found risk assessments supported them to understand people’s needs and we found these were updated when people’s needs changed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Risks associated with peoples care needs were not being managed safely. We found prescription thickener stored in a communal area unlocked and accessible to people. This posed a significant safety risk if someone were to ingest this.

A patient safety alert was issued to all care homes in February 2015 to ensure thickening agents were securely stored. The prescribed thickener had been dispensed in August 2025. No risk assessment was in place, and no staff had identified it was not safe to be left in the open cabinet.

Toiletries were not always stored safely, and remained accessible to people who may not recognise they are not to be eaten or drunk

A patient safety alert was issued to all care homes in February 2015 to ensure thickening agents were securely stored. The prescribed thickener had been dispensed in August 2025. No risk assessment was in place, and no staff had identified it was not safe to be left in the open cabinet.

We found environmental risk assessments were not routinely written or potential risks considered. For instance, a coffee making machine and a hot water urn in a dining area had been in place for some time though the risk assessments were dated 01 April 2026. People and visitors had open access to these, which could have caused scalding if incorrectly used.

People were at an increased risk of harm from fire. Fire drill records did not always demonstrate simulated scenario procedures or fire evacuation equipment being used to ensure staff were adequately prepared in the event of a fire evacuation.

The service had not assured themselves every person who lived at the service had an up to date personal emergency evacuation plan (PEEP) in place. One person had lived at the home for over 6 months, and staff had no details on how best to support them in the event of a fire.

We discussed this with the provider during the assessment who agreed to take immediate action to address these issues. Following our feedback the provider placed torches at each fire exit and ensured all PEEPs held a photograph of each person.

There were systems in place to ensure the equipment, electrical items and gas supplies were safe, in line with legislation.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were regularly reviewed to determine the numbers of staff provided remained sufficient to meet people's needs. Call bells were answered in a timely way. The service benefitted from a stable staff team, many of whom had been with the service for some considerable time.

People and relatives made positive comments about staffing levels at the service. One person told us, “I think the numbers of staff are about right, I have never thought otherwise”. Another told us, “It is a good home, the girls (staff) are all good, they are very professional but in a casual, unrushed way”.

Staff were available to support people as required. There was lots of positive engagement between people and staff. Staff were positive about the staffing levels in the home. Staff members’ comments included, “There is definitely enough staff, we have time to spend with people” and “I think this is the best care home, I feel I have time to spend with people and they are happy”.

The service had a new induction checklist to support staff in the first phase of employment. The induction included an allocated mentor and training that was face to face as well as online. Competence assessments were completed before a staff member could work unsupervised.

Staff supported people in a way which showed they were well trained. Refresher training for established staff was up to date, although competency assessments were inconclusive and did not show if staff met the criteria to provide safe care.

Formal processes supported staff, including regular individual and group development meetings, staff meetings and annual appraisals. Staff told us, “We have regular supervision and the feedback is helpful”.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff received training on infection prevention and control and could describe how they used this knowledge in practice to minimise infection risks. However, we saw some staff wearing nail coverings and beaded bracelets. These prevent effective hand hygiene measures and can present a risk of infection to people and were stated in the provider’s uniform policy.

We saw personal protective equipment (PPE) was readily available and used appropriately and consistently by staff. However, stocks of PPE were stored in the sluice room. We discussed the potential cross infection risks of this approach with the provider, who addressed the issue immediately.

Systems were not effective to ensure all food items were safe to eat. A fridge and a microwave in a communal kitchenette were not maintained and were in need of cleaning. Food items were past their use by date and other items were not dated when opened to ensure they were consumed within the recommended time. This meant there was an increased risk of infection due to practices at the service.

However, the provider had a recent food hygiene rating of 5 which indicates the food hygiene standards are ‘very good’. The provider had plans in place to create a refreshments preparation room for room service staff to use to avoid their need to access the kitchen.

We saw the home was visibly clean and there were no malodours. Cleaning schedules showed cleaning was recorded as having taken place each day.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always stored in a temperature controlled environment in line with manufacturers’ guidance. Secure arrangements for the storage of some medicines were a concern.

Immediate action was taken to address the issues we found, including implementing new security systems to ensure safe storage and disposing of medicines after contacting health professionals.

However, there were examples of good practice. The service had introduced an effective process to ensure time sensitive medicines were administered correctly. Some people were prescribed 'as required' (PRN) medicines, which had clear guidance for their use.

People received medicines in line with their preferences. A person told us, “My medicines are all taken care of. I have always taken a lot of vitamins throughout my life, and I am still allowed to have all those too”.

Another person told us how staff supported them with replacing their leg dressings, “they did it really well today, I am very pleased”.