CQC report explained · a residential care home
What the CQC found at Delrose
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Delrose is rated Requires Improvement; inspectors found widespread safety, staffing, dignity and management problems, although an improvement plan was under way.
Inspectors visited without warning on 28 June and 3 July 2023. They observed care, spoke with people, staff, managers and relatives, and checked care, staff and management records. They also considered information from local authority and NHS professionals involved in a large safeguarding enquiry.
They found that care was not consistently safe, effective, kind, personalised or well managed. Problems included missed safeguarding reports, incomplete risk assessments, unsafe support for people at risk of choking, medicines not always given at the right time, poor cleaning and not enough suitably skilled staff.
The provider was working on a detailed improvement plan and had brought in experienced managers from other locations. By October 2023, the provider reported that 82 of 69 high-priority and 24 medium-priority actions had been completed, with 33 more started and under way. Inspectors said improvements were being made, but they were not yet fully part of everyday practice.
All five CQC areas were rated Requires Improvement. This is a lower rating than the previous Good rating, published in December 2022, and means there was limited assurance that people were consistently safe and receiving good-quality care.
Safe recruitment
The provider had a robust recruitment process and kept records needed to support safer recruitment decisions.
“There was a robust recruitment process which included retention of the necessary records to show evidence of safe recruitment.” from the report
Improvement plan
The provider had a detailed improvement plan and was sharing regular updates about its progress with inspectors.
“The provider was working to a thorough, credible improvement plan at the time of inspection.” from the report
Working with outside professionals
The provider cooperated with the safeguarding enquiry and accepted training and advice from local authority and NHS professionals.
“The provider had cooperated openly with the large scale safeguarding enquiry established by local authority and NHS professionals.” from the report
Learning from the inspection
The provider had introduced a staff skills audit, quality workshops and better supervision and support for night staff.
“The provider had created a learning culture at the service which improved the care people received.” from the report
Safeguarding and risk
seriousSafeguarding incidents were not always reported, and risk assessments were not always maintained or followed. Inspectors found increased risk that people could be harmed.
“People were not always safeguarded from abuse and avoidable harm.” from the report
Choking support
seriousSome people identified as at risk of choking did not receive the right support when eating and drinking.
“For example, people identified as at risk of choking did not receive appropriate support to eat and drink.” from the report
Medicines
seriousPeople did not always receive medicines at the right time, including medicines that care plans said should be taken with food. Some staff were unsure why certain medicines were time critical.
“People did not always receive their medicines at the right time, particularly where care plans stated medicines should be taken with food.” from the report
Staffing and continuity
seriousThe home did not always have enough suitably skilled staff. Staff and managers from other locations were used, but inspectors said this was not sustainable and affected continuity.
“The provider did not always ensure there were sufficient numbers of suitable staff.” from the report
Dignity and choice
needs fixingSome staff treated people with care and offered choices, but others showed little engagement or did not respond quickly when people's dignity was affected.
“People's privacy, dignity and independence were not always respected and promoted.” from the report
Cleanliness and environment
needs fixingCleaning rotas were not consistently followed, and a deep clean did not initially meet the required standard. Some items needed replacement and storage obstructed a fire escape route.
“Staff did not always follow cleaning rotas which meant cleaning was not done regularly or effectively.” from the report
- 01What evidence can you show that safeguarding incidents are now reported correctly and that risk assessments are kept up to date?
- 02How are you checking that staff understand and follow each person's choking guidance and medicines instructions?
- 03How many permanent suitably trained staff are now in post, and how are you maintaining continuity for people who need familiar staff?
- 04How do you check that staff use each person's communication plan, offer genuine choices and protect privacy and dignity?
- 05Who is currently responsible for the home, and what progress has been made in completing the improvement plan since October 2023?
This was an unannounced inspection of all five CQC question areas, including the premises and care provided; all five ratings were reassessed and changed from Good to Requires Improvement. This explanation was written from the published report of 2 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Rated Good; inspectors found safe, kind and well-managed care, with support plans being updated.
This was an unannounced focused inspection on 26 and 28 September 2022. One inspector observed care, spoke with the manager, two staff members and one person, and checked care and recruitment records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found enough trained staff, safe medicines practice, suitable risk assessments and effective infection control. People received personalised support and were helped to make choices and stay as independent as possible.
The overall rating was Good, the same as at the previous inspection published in February 2021. This inspection did not assess Caring or Responsive. Their previous ratings were used when calculating the overall rating.
Choice and independence
People were supported to have control over their lives. Restrictions were used only when necessary and risks were managed in ways that preserved freedom.
“The service supported people to have as much choice, control and independence as they could.” from the report
Kind, individual care
Staff understood people's communication, preferences and behaviours. Inspectors found that care was kind and respected privacy and dignity.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Staffing and medicines
The home had enough staff, including for one-to-one support. Staff followed safe systems for administering, recording and storing medicines.
“The numbers and skills of staff matched the needs of people using the service.” from the report
Safe environment
The home was clean and well maintained. Fire safety checks and evacuation planning were in place, and a lift had been installed for wheelchair users.
“People's care and support was provided in a safe, clean, well-maintained environment which met people's needs.” from the report
Open management
Managers were visible and approachable. The home used audits, staff feedback and improvement plans to check and develop the service.
“The provider promoted a positive, inclusive culture.” from the report
Inspectors raised no specific concerns in this report.
- 01How will the move from paper support plans to a computer-based system affect my relative's care and access to their records?
- 02What extra communication training are staff receiving for people who do not express themselves verbally?
- 03How will you make sure my relative continues to have choice and independence when risks or periods of distress arise?
- 04How do you check that medicines prescribed to be taken as required are still appropriate and given safely?
- 05How will my relative and their family be involved in reviews and decisions about their support?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 10 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Delrose
7 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2022Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- February 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 19 May 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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