Bournemouth Rainbow Ltd

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 breaches of legal regulations in relation to people’s safe care and treatment and safeguarding.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a proactive and positive culture of safety. They did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff told us they knew how to raise concerns with the management team.

However, we found the system in place to record incidents and accidents was not used effectively. There was no agreed process for reporting incidents and accidents. Records confirmed some incidents were reported over the phone, some were recorded on the electronic care recording system, and others were reported by email. This meant the provider did not have an effective oversight of incidents and accidents. The provider did not have an effective process for learning from incidents and accidents. The management team told us that lessons learned were discussed in the office, however there were no records to demonstrate that this happened. The provider could not assure themselves lessons were learned from incidents or that appropriate action was taken when required.

This placed people at risk, as opportunities to identify patterns, address concerns, and improve the safety and quality of care may have been missed.

The service worked with people and healthcare partners to establish and maintain systems of care. They made sure there was continuity of care, including when people moved between different services.

People had summaries of their needs, known as hospital passports, which were stored in their homes. These were available to emergency services in the event of an unplanned hospital admission.

Health and social care professionals were complimentary about the service and told us the provider had been responsive when changes were required.

A health and social care professional told us, “The provider has maintained good communication with me and the family members of the individuals we support. They have also provided a consistent approach to delivering care and support.”

The provider did not have an effective system in place to monitor safeguarding concerns.

People’s daily notes were checked regularly, and an overview of what had happened during the day was recorded on the provider’s spreadsheet. Records showed some people suffered unexplained bruising. This information was not investigated or acted upon. This meant the provider could not be assured people had not experienced avoidable harm. Additionally, the failure to act placed people at increased risk of experiencing avoidable harm.

The provider failed to report concerns, such as unexplained bruising, to the local authority. The provider did not maintain an overview of safeguarding concerns or have an established system for reporting them. As a result, some concerns were emailed to an incorrect email address, while others were not reported at all. This meant the provider failed to ensure effective and robust processes and systems were in place to protect people from neglect and improper treatment.

We raised our concerns with the local authority safeguarding team during this inspection.

Staff received safeguarding training and told us they knew how to report safeguarding concerns to the management team and external organisations, such as the CQC.

The service did not always work well with people to understand and manage risks. They did not always provide safe care to meet people’s needs.

The provider did not always ensure appropriate risk assessments were in place. For example, some people’s hoisting needs had been risk assessed, while others had not.

While risk assessments were in place in some areas, they were not always accurate. For example, the equipment risk assessment for a person who had sustained an equipment related injury, did not include information on how to reduce the likelihood of a recurrence. As a result, the person was placed at risk of avoidable harm when using the equipment.

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

Some people using the service required staff to use a hoist to move them safely. The provider did not always maintain effective oversight of the safety of equipment used to transfer people. For example, 1 person’s hoist had not undergone a safety inspection in accordance with the Lifting Operations and Lifting Equipment Regulations (LOLER) for a year. The provider did not have an effective system in place to ensure staff used equipment that had been checked and deemed safe to use. This placed people at risk of avoidable harm.

We raised our concerns with the local authority safeguarding team during this inspection.

Some environmental risk assessments were in place and provided information about risks within people’s homes. These included areas such as gas safety, poor external lighting, and household pets.

The provider did not ensure staff were suitably qualified and skilled to provide safe care to people.

People using the service had learning disabilities. The provider failed to ensure staff received training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role. This meant the provider could not be assured staff had the required competencies to support people safely and in a way that promoted their dignity, independence, and wellbeing. In response to our feedback, the provider booked the necessary training for staff. However, this training had not yet been completed by all staff at the time of our inspection.

Recruitment processes in place were not always followed. For example, the provider did not always obtain staff’s full employment histories. In response to our feedback, the provider introduced a new system and began reviewing the recruitment files for all staff during the inspection.

Staff received supervision and their work performance was checked through competency assessments.

The service assessed and managed the risk of infection.

Relatives told us staff worked in a safe and hygienic way.

We observed staff worked in line with good practice, changed their gloves regularly, and kept people’s homes clean and hygienic.

Staff confirmed they had access to personal protective equipment.

The provider had an infection control policy in place, and staff had access to relevant training.

The service did not make sure that medicines and treatments were safe.

Some medicine training was provided to staff by a staff member who did not have the qualification to deliver this training. This meant staff did not complete the practical element of their training required to administer rescue medicine to 1 person. This meant staff were not adequately trained which placed a person at risk of avoidable harm.Following our inspection the provider conducted additional refresher training and carried out updated competency checks.

We raised our concerns with the local authority safeguarding team during this inspection.

Records showed people’s allergies were inconsistently recorded on their medicine administration records. For example, 1 person’s medicine allergy was recorded on some pages of their paper Medication Administration Record (MAR) but was omitted from others. This increased the risk staff may not have had access to accurate and consistent information when administering medicines, potentially placing the person at risk of harm.