Bournemouth Rainbow Ltd

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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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 54 (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 clear shared vision, strategy and culture. They did not always understand the challenges and the needs of people and their communities.

Staff told us they felt part of a team, and enjoyed working at the service. A staff member said, “[The management team] encourage open communication, listen to staff, and take concerns seriously. Team meetings, supervision, and day-to-day communication provide opportunities to discuss ideas and any issues that arise.”

While the provider was responsive during our inspection process and took steps to address concerns raised during our feedback, they had not been proactive in identifying and addressing shortfalls identified during this inspection.

Not all leaders understood the context in which the service delivered care, treatment and support. The management of the service did not always have the skills, knowledge, experience and credibility to lead effectively.

Relatives were complimentary about the management of the service.

Staff were not always aware of who the registered manager was, however they were complimentary about the management of the service.

A staff member said, “I believe the management team promotes equality, respect and inclusion. Staff and the people we support are treated with dignity and respect, and everyone’s views and individual needs are considered.”

While staff confirmed the management demonstrated compassionate and inclusive leadership by listening to their concerns and providing support to them, our inspection found significant shortfalls in relation to safe care and treatment, safeguarding, and good governance.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew how to raise concerns through whistle blowing procedures, and report concerns to external organisations when necessary.

One staff member said, “I can speak openly with my manager during team meetings or supervision. I report concerns quickly and share ideas to improve clients’ safety and wellbeing.” Another staff member told us, “I feel that staff are encouraged to speak up if they have concerns about the people we support, their colleagues or their working environment.”

The provider had an up-to-date policy on speaking up and staff received safeguarding training.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they felt valued and the provider was flexible when they needed time off for any reason. A staff member said, “The organisation promotes equality, diversity, and inclusion. Everyone is treated fairly and with respect, and there are equal opportunities for all staff.”

New staff completed a health questionnaire form as part of the application process. This enabled the provider to identify whether any reasonable adjustments were required to support staff to perform their role effectively and safely.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider failed to ensure there was robust oversight of potential safeguarding concerns, accidents, and incidents. This placed people at increased risk of avoidable harm.

The provider failed to identify staff were not always trained to support people in line with their assessed needs. This meant the provider could not be assured staff had the appropriate knowledge, skills, and competencies to meet people’s needs.

The provider failed to keep people safe. They failed to identify that 1 person had experienced significant weight loss and did not take appropriate action. This placed people at increased risk of avoidable harm.

The provider failed to identify potential risks to people were not always assessed, monitored, or mitigated.

The provider failed to identify the equipment in people’s homes had not always been examined or deemed safe to use. The provider did not maintain records of the equipment checks that were completed and therefore could not assure themselves the equipment was deemed safe to use.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur within a service. We found the provider had not always submitted notifications in line with the regulations. The provider submitted these retrospectively during the inspection. Notifications are important because they support us to monitor the services we regulate.

We found widespread and significant shortfalls in the governance of the service.

Following our inspection the provider developed a new audit tool to support oversight and monitoring of the quality and safety of the service.

The service did not always understand their duty to ensure services worked seamlessly for people.

Staff understood their duty to collaborate and work in partnership.

Staff told us they communicated with health and social care professionals, and records confirmed this.

However, we found that this was inconsistent depending on the type of health concern related.

The provider did not always demonstrate a clear understanding of how to drive and sustain improvements within the service.

Our inspection found widespread and significant shortfalls which were not identified or addressed through the provider’s quality management systems.

While the provider started to make changes in response to our feedback, these improvements had only recently been implemented and had not yet been embedded into practice. Further improvements were needed to ensure changes were monitored and sustained.