CQC report explained · a nursing home
What the CQC found at Dora Rose Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk checks, repositioning records and care plans were not always complete or current. Medicines monitoring also had gaps, although staffing, recruitment and infection control were found to be satisfactory.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the last inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the last inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the last inspection.
- Well-led?
- Requires improvement
- Quality monitoring systems did not identify missing or outdated information in care records. The provider introduced improvements, but CQC will assess whether these are effective at the next inspection.
What inspectors found, March 2023
Dora Rose Care Home is rated Requires Improvement; inspectors found gaps in risk, medicines and care-record monitoring, although staff responded to improvements.
This was an unannounced focused inspection on 15 and 22 December 2022. Inspectors looked only at Safe and Well-led, following concerns about care monitoring and records. They spoke with people, relatives, staff and a visiting professional, and checked care, medicines, recruitment and management records.
Some risks were not monitored consistently. Records did not always show that people had been repositioned or had required health checks. Care plans were not always updated when people's needs changed. Medicines monitoring also had gaps, including missing checks for skin patches and an outdated covert medicines protocol.
There were also positive findings. Inspectors found enough staff, safe recruitment, effective infection control and kind responses to people. People and relatives said they felt safe and could raise concerns. The provider acted during and after the inspection by improving audits, medicines checks and care records.
The overall rating changed from Good to Requires Improvement. Safe was rated Requires Improvement, and Well-led remained Requires Improvement. The other three ratings were carried over from the previous inspection because they were not inspected.
Staffing and recruitment
Inspectors found enough staff to meet people's needs and found that recruitment checks had been completed safely.
“There were enough staff on duty to support people's needs and staff were recruited safely.” from the report
Infection control
Staff used protective equipment correctly and the home had arrangements for preventing and managing infections.
“Staff used personal protective equipment (PPE) effectively and received infection prevention control training.” from the report
Kind support
Staff answered call buzzers promptly and were observed supporting people with kindness and patience.
“We observed staff responding kindly and patiently to people who needed assistance.” from the report
Listening to people
People, relatives and staff had regular opportunities to give feedback. The home shared actions through meetings and notices.
“Resident, relative and staff engagement was embedded throughout the service.” from the report
Learning from problems
The provider reviewed incidents and acted on the inspection findings by strengthening medicine audits and updating care plans.
“Lessons were learnt from the findings from this inspection.” from the report
Incomplete safety monitoring
seriousSome required checks were missing, including blood sugar readings and repositioning records. This meant inspectors could not be sure that care was always delivered and recorded as planned.
“Risks to people were not always monitored in line with the care plan.” from the report
Outdated care plans
needs fixingCare plans did not always reflect changes made by health professionals. Staff were also not always familiar with people's health conditions and care instructions.
“Care plans were not always kept up to date with changes in people's care requirements.” from the report
Medicine recording gaps
seriousMonitoring systems for pain relief and other skin patches were not reliable. One person went without a prescribed patch for three days because of a handover error.
“One person went without this patch for 3 days.” from the report
Weak quality checks
seriousAudits did not identify missing or outdated information in care records and medicines records. CQC found this was a breach of the regulations.
“Systems were either not in place or robust enough to demonstrate effective quality assurance management and risk monitoring.” from the report
- 01How are you now checking that care plans are updated promptly when a person's needs or professional advice changes?
- 02How do you record and check repositioning, blood sugar readings, fluid intake and other regular care tasks?
- 03What new checks are in place to make sure skin patches and covert medicines are administered and recorded correctly?
- 04What progress has been made with the action plan for the Regulation 17 breach, and when will the new audits be reviewed?
- 05Has the new manager's application to become registered been completed?
This was an unannounced focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried over from the previous inspection. This explanation was written from the published report of 8 March 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, October 2021
Dora Rose Care Home was rated Good overall, with kind and safe care but weaknesses in records and quality checks.
Inspectors visited on 29 June 2021. The visit was unannounced, with three inspectors. They spoke with people and staff, observed care, and checked care, medicines, staffing and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines practice, suitable training, good infection control, kind care, personalised support and activities. People said they were happy with the care and food.
Well-led was rated Requires Improvement. Some records about fluids, weight, repositioning and health monitoring were inaccurate. Inspectors were concerned this could affect how well the home monitored people's health. The provider said the electronic records system had problems and introduced paper records as a temporary measure after the visit.
This was the first inspection since the service registered. The overall Good rating means inspectors judged the care to be good overall, but the management and record-keeping weaknesses need attention.
Safe staffing and medicines
Inspectors found enough staff to respond to people's needs and found that medicines were administered and recorded safely.
“Throughout our visit we saw staff responding to the needs of the people living there in a timely manner.” from the report
Kind and respectful care
People described staff as kind. Inspectors observed respectful interactions, choices being offered and support for independence.
“We observed many respectful and compassionate interactions during the inspection” from the report
Personalised support
Care plans covered people's wishes, health, diet, communication needs and interests. Plans were reviewed with input from people, families and professionals.
“Each person living at the home had a personalised plan of care that included information about their wishes, interests and hobbies, health, diet and communication needs.” from the report
Activities and family contact
The home had dedicated activity staff, organised social events and supported people to keep in touch with friends and family.
“The home organised social events for people and their friends and families” from the report
Inaccurate care records
needs fixingRecords about fluids, weight, repositioning and health monitoring were not always accurate. Inspectors said this could affect the home's ability to monitor people's health effectively, although no harm had been caused.
“People could not be assured accurate records were being kept of the care provided to them.” from the report
Governance needed strengthening
needs fixingInspectors were not assured that the home would always act promptly when its checks identified problems. The provider said there were problems with the electronic care records system and introduced paper records after the inspection.
“People could not be assured the home would always act in a timely manner when the governance systems identified issues that needed addressing.” from the report
- 01Have the problems with the electronic care records system been fully resolved?
- 02Are paper records still being used, and how are they checked for accuracy?
- 03How do you now check records about fluids, weight, repositioning and health monitoring?
- 04What happens when a quality check identifies a problem, and how quickly is it fixed?
- 05How will you show families that these improvements have been sustained?
This was the first planned inspection of the newly registered nursing home and covered all five key questions, including infection prevention and control during the COVID-19 pandemic. This explanation was written from the published report of 21 October 2021 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 Dora Rose Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021GoodSafe: GoodWell-led: Requires improvement
- November 2019
Registered with the Care Quality Commission on 15 November 2019.
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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