CQC report explained · a nursing home
What the CQC found at Rashwood
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, staff understood safeguarding, and there were enough staff. Inspectors found some environmental risks and one medicine had not been given as prescribed.
- Effective?
- Good
- No rating was given for this question in this report.
- Caring?
- Good
- No rating was given for this question in this report, although inspectors described staff as consistent and caring.
- Responsive?
- Good
- No rating was given for this question in this report.
- Well-led?
- Requires improvement
- Management checks had not found gaps in records and some reporting duties were not completed. People and staff said the manager was approachable and feedback was used to make some changes.
What inspectors found, October 2022
Rated Good overall; inspectors found people felt safe and cared for, but management checks and records needed improvement.
Inspectors visited on 10 and 24 August 2022. The first visit was unannounced and the second was announced. They spoke with seven people, one relative and 10 staff, and checked care, medicines, recruitment, training and management records.
People told inspectors they felt safe. There were enough staff, call bells were answered promptly, and staff understood safeguarding. Inspectors also found a caring and positive staff culture, with people and staff able to suggest improvements.
The main weakness was management oversight. Checks had not found gaps in care records, monitoring charts and environmental safety. One medicine was not given as prescribed, one health referral was not followed up promptly, and a serious injury had not been reported to the CQC. The overall rating stayed Good, but Well-led fell from Good to Requires Improvement.
Staffing
Inspectors found enough staff to support people safely. Call bells were answered promptly, and the home was continuing to recruit.
“There were enough staff to support people safely. People were generally happy with the staffing levels in the home.” from the report
Caring staff culture
People were supported by a consistent staff group who knew them. Staff described a positive working environment.
“Staff felt listened to and there was a positive working culture within the service.” from the report
Listening to feedback
People and staff could make suggestions, and inspectors found examples of changes made following their feedback.
“People told us they attended 'residents' meetings' where issues they raised were acted on.” from the report
Management checks missed problems
needs fixingQuality checks did not identify some gaps and conflicting information in care records. Environmental checks also needed improvement.
“The providers quality assurance systems were not always effective and had not found issues we identified during the inspection.” from the report
Environmental safety
needs fixingInspectors found a door open when it should have been closed and alarmed. The manager acted during the inspection, but the risk assessment needed more work.
“a door which should have been closed and alarmed, was found open and the alarm not activated.” from the report
Medicine recording
seriousOne person's medicine was not given as prescribed, and there was no clinical note explaining why. The provider said an electronic records error was corrected.
“We found a person's medication had not been administered as prescribed and there were no clinical notes to explain why this was.” from the report
Incident reporting
seriousA serious injury had not been reported to the CQC. The provider also had not always followed its duty to be open and honest with people after something went wrong.
“we identified a serious injury the registered manager had failed to notify us about.” from the report
- 01What changes have you made to quality checks so gaps and conflicting information in care records are found promptly?
- 02How do you now check that food, fluid and pressure-relief monitoring charts are complete?
- 03What checks are in place to make sure medicines are given as prescribed and electronic records are accurate?
- 04How do you make sure serious injuries, statutory notifications and written responses after incidents are reported on time?
- 05What action has been taken to make sure doors and areas containing potentially harmful items are kept secure?
This inspection rated Safe and Well-led; no ratings were given for Effective, Caring or Responsive in this report. This explanation was written from the published report of 26 October 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.
What inspectors found, December 2019
Rated Good; inspectors found kind, personalised care, with some medicine storage and expiry checks needing attention.
This was a planned inspection over 11 and 12 November 2019. One inspector, a nursing specialist and an Expert by Experience visited. They spoke with people, relatives, staff and a health professional, observed care, and checked care, medicine and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with dignity, involved in decisions and supported according to their needs and preferences. Staff were trained, staffing was considered sufficient, and people had access to food, activities and health professionals.
There was one medicine-related shortfall. Storage temperatures had not always been reset, and one skin cream was past its use-by date. Inspectors found no evidence of harm, and the registered manager said this would be addressed immediately. The overall rating remained Good, as it had been at the previous inspection published on 11 May 2017.
Kind and respectful care
People and relatives said staff were considerate, caring and respectful. Staff supported privacy, dignity and independence.
“People and relatives highlighted how considerate staff were when care was provided.” from the report
Personalised support
Care was based on people's histories, risks, choices and changing preferences. People and relatives were involved in planning and reviewing care.
“People's care plans reflected their personal histories, risks and care preferences.” from the report
Good leadership
People, relatives and staff described the home as well managed. Managers checked the quality and safety of care and encouraged staff to suggest improvements.
“People and relatives told us the way the home was managed led to good care, which was provided by a consistent group of motivated staff.” from the report
Activities and relationships
People enjoyed regular activities, social opportunities and time with relatives. Staff adapted activities to people's physical, sensory, spiritual and personal needs.
“People told us they enjoyed the regular activities available in the home.” from the report
Medicine storage and expiry checks
needs fixingMedicine storage temperatures were not always reset, and one person's skin cream was past its use-by date. Inspectors found no evidence of harm, but said this increased the risk that medicines might not work effectively.
“Staff had not consistently re-set the temperatures where people's medicines were stored in November 2019. We also found an instance where one person's skin cream was passed its use by date.” from the report
- 01What changes were made after the inspection to make sure medicine storage temperatures are reset and recorded consistently?
- 02How do you check that creams and other medicines are within their use-by dates?
- 03How will you involve my relative in decisions about their daily routine, care preferences and activities?
- 04How will you support my relative's communication needs if they need information in another format, such as large print?
- 05What support would be provided to my relative and our family if end-of-life care became necessary?
This was a planned inspection covering all five key questions, including the care provided, the premises, records, medicines and how the home was managed. This explanation was written from the published report of 19 December 2019 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 Rashwood
4 rated inspections over 8 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- May 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Inspected but not ratedEffective: Requires improvement
- March 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 January 2011.
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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