Rushall Care Home

This unannounced assessment was carried out in response to emerging risk.

We assessed the service against ‘Right support, right care, right culture’ to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choice, independence and access to local communities that most people take for granted. We found the service was not consistently delivering care in line with these standards.

We found the service was not consistently delivering care in a way that met people’s individual needs or protected them from avoidable harm. Staff were not always provided with clear or accurate guidance to support people safely and consistently. This was particularly evident for people living with learning disabilities, mental health conditions, emotional distress and long‑term health conditions.

Leaders and staff did not always recognise or respond appropriately to risk. We identified unsafe medicines management practices, including unsecured topical medicines accessible to people living with dementia. There were also significant shortfalls in how emotional distress and behaviours were understood, recorded and responded to, with staff often relying on personal judgement rather than structured guidance or evidence‑based approaches.

Safeguarding processes were not always effective as the provider did not consistently identify incidents that met safeguarding thresholds. As a result, risks of abuse, neglect and inappropriate restraint were not fully recognised or mitigated.

Governance systems failed to provide effective oversight and opportunities to learn from incidents were sometimes missed.

Despite the concerns identified during this assessment, there were examples of positive practice across the service. Most people and relatives described many staff as kind, caring and familiar with people’s individual preferences and needs. Staff were observed interacting respectfully with people. The service worked with GPs, therapists and specialist teams to support people to access to healthcare.

Recruitment and induction processes were in place to ensure staff had the appropriate core skills and many staff described a supportive team culture and positive working relationships. Medicines were generally ordered, administered and recorded safely, and infection prevention and control systems were established, with people and relatives describing the home as clean and well maintained.

The provider was in breach of the legal regulations relating to person-centred care, safe care and treatment, safeguarding and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.