CQC report explained · a nursing home
What the CQC found at Roborough House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Medicines, risk assessments, staffing checks, infection control and emergency arrangements had improved.
- Effective?
- Requires improvement
- Staff training and support had improved, and people received suitable care and treatment. However, the new systems were not yet fully embedded, and training records did not include most nursing posts because these were filled by agency nurses.
- Caring?
- Good
- This focused inspection did not assess Caring.
- Responsive?
- Good
- This focused inspection did not assess Responsive.
- Well-led?
- Requires improvement
- Leadership and oversight had improved, with new audits, meetings and systems. However, the manager was temporary, there had been several managers in recent years, and the improvements needed to become established.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found safer care, but effectiveness and leadership still needed to improve.
This was an unannounced focused inspection on 6 December 2022. Three inspectors, including a pharmacist inspector, visited the home. They spoke with six people and 12 staff, observed care, and checked care, medicines, staff and management records.
The home was rated Good for Safe. Inspectors found improvements in safeguarding, risk assessments, medicines, staffing checks, infection control and emergency planning. People appeared happy and relaxed, and staff responded promptly when people were distressed.
Effective and Well-led were both rated Requires Improvement. New training, care, medicines and auditing systems had been introduced, but they had not been in place long enough to show they were fully embedded. The home had also had three managers in three years and had no registered manager at the inspection.
The home had been in special measures after the May 2022 inspection, when it was rated Inadequate and breached regulations. At this inspection it was no longer Inadequate or in special measures, and the previous breaches were no longer continuing.
Improved medicine safety
Inspectors found that medicines were now recorded and given as prescribed. There were also clearer instructions for medicines given when needed.
“These records showed that people now received their medicines safely in the way prescribed for them.” from the report
Better safeguarding
Safeguarding concerns were now passed to the appropriate organisations, and CQC notifications were being made when required. Professionals said people were safer.
“Professionals felt people were now safer in the service.” from the report
Staff understood people's risks
Risk assessments had been updated, and staff received daily information about changes in people's needs. Emergency and fire safety arrangements were also in place.
“Risk assessments had been updated and completed and now showed full details which meant staff had guidance on how to manage people's care safely.” from the report
Kind and calm interactions
Inspectors observed people appearing happy and relaxed. Staff responded promptly when people seemed distressed.
“The interactions between people and the staff supporting them showed people were happy and relaxed.” from the report
Improved staff support
Staff had more training, supervision and support than at the previous inspection. New staff were supported through induction and shadowing.
“Staff told us they were now provided with opportunities to discuss their individual work and development needs.” from the report
Leadership was not yet stable
needs fixingThe manager at the inspection was temporary and was the third manager in three years. A new permanent manager was expected, but inspectors needed to see whether improvements continued.
“The current manager who had introduced considerable improvements into the service, was only employed on a temporary basis” from the report
New systems needed to become routine
needs fixingAudits and other processes had improved, but they had only recently been introduced. Inspectors could not yet be confident that they would continue to work consistently.
“However, these systems and processes had not yet been embedded into the operation of the service.” from the report
Reliance on agency nurses
needs fixingThe home still used many agency staff, particularly nurses. Most nursing training records were not included in the home's training system because of this.
“The service still used a high number of agency staff, in particular nurses.” from the report
- 01Who is now the permanent manager, and are they registered with CQC?
- 02How have the new care, medicines and auditing systems been kept working since the inspection?
- 03How many nurses are agency staff now, and how are their training and competence checked?
- 04What actions are being taken to keep the improvements in place after the interim manager leaves?
- 05How are safeguarding concerns, accidents and deaths reported and reviewed now?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed in this report. This explanation was written from the published report of 26 January 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, September 2022
Rated Inadequate and remains in special measures; inspectors found serious problems with medicines, safeguarding and management.
This was an unannounced focused inspection on 26 May 2022. Three inspectors, including a pharmacist inspector, visited the home. They spoke with people, relatives, staff and professionals, and checked care records, medicine records, staff files and management records.
The home was rated Inadequate overall. Safe and well-led were rated Inadequate. Effective was rated Requires Improvement. Inspectors found repeated problems with medicines, risk assessments, safeguarding referrals, infection control, staff training, record keeping and management checks.
There were some positive findings. Staff were seen to be kind and attentive. The building and equipment were generally safe, people had access to food and drinks, and mental capacity and liberty safeguards were generally handled appropriately. However, the serious shortfalls meant people were at risk of avoidable harm.
Kind interactions
Inspectors saw staff being attentive, kind and caring when supporting people.
“Staff were observed as attentive, kind and caring.” from the report
Food and drinks
Inspectors found that people were offered healthy meals and regular drinks. People staying in their rooms had drinks refreshed during the day.
“People were provided with healthy meals. Hot and cold drinks were served regularly throughout the day to prevent dehydration.” from the report
Emergency arrangements
The environment was considered safe, and emergency evacuation plans and fire safety checks were in place.
“Emergency plans were in place outlining the support people would need to evacuate the building in an emergency.” from the report
Medicines were not reliably managed
seriousSix people's medicine records had one or more gaps. Inspectors could not always tell whether medicines had been given, and important pain relief had run out for one person.
“Medicines records showed that people did not always receive their medicines in the way prescribed.” from the report
Safeguarding failures
seriousSerious injuries linked to harm by other residents had not been referred to the local safeguarding team. Required notifications were also not sent to CQC.
“This information had not been reported to the local safeguarding team, and no advice had been sought to protect people or prevent any further injuries.” from the report
Staff training and support
needs fixingTraining records did not show staff names or completion dates. Some staff said they had received no induction or supervision, and nursing staff had no clinical supervision.
“Some staff stated they had not had any induction or supervision since they started at the service.” from the report
Infection control was inconsistent
needs fixingSome staff did not wear masks correctly. Visitors were asked to test before every visit, although inspectors said this was not current government guidance.
“Staff did not always wear their masks covering their nose and mouths.” from the report
Heavy use of agency staff
needs fixingThe home used many agency staff, including agency nurses. Inspectors said this could mean staff did not know people and the home's systems well enough.
“The service relied on a high use of agency staff to fill these vacancies, particularly for people who required one-to-one support.” from the report
- 01What changes have been made to stop gaps in medicine records, prevent medicines running out and ensure prescribed medicines are given correctly?
- 02How are safeguarding incidents now reported to the local authority and CQC, and how are risks reviewed after an injury or incident?
- 03Which staff have completed the required training, induction and supervision, and can you show dated records?
- 04How many agency staff are currently used on each shift, and how do you check that staffing levels and staff knowledge are safe for each person?
- 05What action plan was sent to CQC, what monthly reports are being provided, and what improvements have been checked since this inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and no ratings were given for them. This explanation was written from the published report of 21 September 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 Roborough House
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- January 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvement
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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