CQC report explained · a nursing home
What the CQC found at Red Rose Care Community
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2022
Overall Requires Improvement; inspectors found kind and effective care, but medicines monitoring, mask use and quality checks needed improvement.
This was an unannounced focused inspection on 18 May 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home had enough staff on the inspection day. People were treated kindly and respectfully, received effective support with food and healthcare, and were involved in decisions about their care. The home had adapted its layout for people with different levels of dementia.
There were safety concerns about reviewing some as-needed medicines, instructions on one medicines record, interruptions during one medicines round, and staff not always wearing masks correctly. Management checks had not found all these problems. The home was no longer in breach of regulations from the previous inspection, but the overall rating remained Requires Improvement.
Staffing and support
Inspectors saw enough staff on duty and people said staff responded to their needs. Staff, including agency staff, had completed induction training.
“Enough staff were available to respond to people's needs in a timely manner.” from the report
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors saw respectful, compassionate and person-centred interactions.
“People were supported, respected and well cared for.” from the report
Effective care
People's needs and choices were recorded in care plans. Staff worked with healthcare professionals and responded when people's needs changed.
“People's outcomes were consistently good, and people's feedback confirmed this.” from the report
Adapted dementia support
The home changed its layout to separate people with different levels of dementia. Families said people were calmer and more settled after the changes.
“Since the changes everyone had been calmer and more settled.” from the report
Medicines monitoring
seriousSome as-needed medicines had not been reviewed within the home's required timeframe. One time-specific medicine lacked instructions on its administration record, and interruptions created a risk of delay on the third floor.
“This meant PRN may be given incorrectly.” from the report
Face mask use
needs fixingStaff were seen wearing masks below their nose or chin, and one removed a mask while speaking with an inspector. The manager said this would be addressed immediately.
“Staff were seen throughout the day with their masks under their nose or under their chin.” from the report
Quality checks
needs fixingThe audit system did not identify all the medicines issues found by inspectors. The provider was asked to improve the audit tool so it covered all possible shortfalls.
“We recommend the provider review their audit tool to incorporate all potential shortfalls.” from the report
- 01What changes have been made to the third-floor medicines round to prevent interruptions and delays?
- 02How do you now make sure as-needed medicines are reviewed within the required timeframe?
- 03How do you check that every medicines administration record contains clear instructions?
- 04What action was taken after staff were seen wearing masks incorrectly?
- 05What changes have been made to the audit tool, and how do you know it now identifies medicines and infection-control problems?
This was a focused inspection covering Safe, Effective, Caring and Well-led; Responsive was not covered in this report. This explanation was written from the published report of 3 August 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, November 2020
Rated Requires Improvement; inspectors found good responsive care, but staff induction and training were not always completed safely.
This was a focused inspection on 6 October 2020. Inspectors checked whether the home had followed its action plan, and looked at Safe, Responsive and Well-led. They spoke with one resident, 10 relatives and 12 staff, and reviewed care, medicines, staff and management records.
The home had enough staff on duty during the inspection, and people received medicines safely. Care plans reflected people's needs. Relatives gave positive feedback, and people were supported to keep in touch and take part in activities during the COVID-19 pandemic.
However, some new staff had not completed their induction or mandatory safety training promptly. Agency workers had not always received a formal induction. Some frequently touched areas also needed more cleaning. These issues meant the home remained in breach of Regulation 18 about staffing.
The overall rating remained Requires Improvement. Safe and Well-led were also Requires Improvement, while Responsive improved from Requires Improvement to Good. The home was no longer in breach of the earlier regulations about safeguarding, risk management, personalised care and governance.
Kind and welcoming care
Relatives spoke positively about the care and communication. Staff supported people to maintain contact with relatives and helped reduce isolation.
“We found the service to be warm and welcoming.” from the report
Personalised support
Care plans reflected people's current needs, including personal and oral healthcare. Daily records showed staff followed these plans.
“Daily records were person-centred and detailed, notes showed that staff followed care plans.” from the report
Medicines managed safely
Inspectors found medicines were given safely and on time. Records checked were accurate and up to date, and staff had competency checks.
“People received their medicines safely and on time.” from the report
COVID-19 precautions
There was enough protective equipment, staff used it correctly and testing had been introduced. No COVID-19 outbreak was present at the inspection.
“At the time of this inspection all people and staff had tested negative for COVID-19 infection.” from the report
Incomplete staff induction and training
seriousSome new staff had worked for more than six weeks without key safety training. Agency workers had not always received a formal induction, creating a potential safety risk.
“This meant that people were at potential risk of harm because staff were not always fully aware about providers internal procedures.” from the report
- 01How do you now make sure every new staff member completes induction and mandatory safety training before working with residents?
- 02How are agency workers introduced to residents' preferences, needs and safety procedures at the start of each shift?
- 03What changes have you made to the induction programme and training matrix since this inspection?
- 04How do you check that high-use touch points such as door handles and handrails are cleaned and disinfected often enough?
- 05What progress has been made on the action plan requested by CQC, and when was it last reviewed?
This was a focused inspection of Safe, Responsive and Well-led, including infection control under Safe; Effective and Caring were not inspected and their previous ratings carried over. This explanation was written from the published report of 20 November 2020 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 Red Rose Care Community
4 rated inspections over 3 years: the service has improved, from Inadequate to Requires improvement.
- August 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2019InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- June 2018
Registered with the Care Quality Commission on 18 June 2018.
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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